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Mück A, Pfeuffer S, Mir L, Genau S, Emde J, Olbricht L, Omar OA, Blaes F, Best C, Huttner HB, Krämer HH. Myasthenic crises are associated with negative long-term outcomes in myasthenia gravis. J Neurol 2024:10.1007/s00415-024-12478-y. [PMID: 38839637 DOI: 10.1007/s00415-024-12478-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Revised: 05/24/2024] [Accepted: 05/26/2024] [Indexed: 06/07/2024]
Affiliation(s)
- Anna Mück
- Department of Neurology, Justus Liebig University, Klinikstrasse 33, 35392, Giessen, Germany.
| | - Steffen Pfeuffer
- Department of Neurology, Justus Liebig University, Klinikstrasse 33, 35392, Giessen, Germany
| | - Lara Mir
- Department of Neurology, Justus Liebig University, Klinikstrasse 33, 35392, Giessen, Germany
| | - Sonja Genau
- Department of Neurology, Justus Liebig University, Klinikstrasse 33, 35392, Giessen, Germany
| | - Julia Emde
- Department of Neurology, Justus Liebig University, Klinikstrasse 33, 35392, Giessen, Germany
| | - Linus Olbricht
- Department of Neurology, Justus Liebig University, Klinikstrasse 33, 35392, Giessen, Germany
| | - Omar A Omar
- Department of Neurology, Justus Liebig University, Klinikstrasse 33, 35392, Giessen, Germany
| | - Franz Blaes
- Department of Neurology, Klinikum Oberberg, Gummersbach, Germany
| | - Christoph Best
- Department of Neurology, Philipps-University, Marburg, Germany
| | - Hagen B Huttner
- Department of Neurology, Justus Liebig University, Klinikstrasse 33, 35392, Giessen, Germany
| | - Heidrun H Krämer
- Department of Neurology, Justus Liebig University, Klinikstrasse 33, 35392, Giessen, Germany
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2
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Hawkes MA, Wijdicks EFM. Improving Outcome in Severe Myasthenia Gravis and Guillain-Barré Syndrome. Semin Neurol 2024; 44:263-270. [PMID: 38560985 DOI: 10.1055/s-0044-1785509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
When progressive and severe, myasthenia gravis and Guillain-Barré syndrome may have the potential for fatal and unfavorable clinical outcomes. Regardless of important differences in their clinical course, the development of weakness of oropharyngeal muscles and respiratory failure with requirement of mechanical ventilation is the main driver of poor prognosis in both conditions. The need for prolonged mechanical ventilation is particularly relevant because it immobilizes the patient and care becomes extraordinarily complex due to daily risks of systemic complications. Additionally, patients with myasthenia gravis often require long-term immunosuppressive treatments with associated toxicity and infectious risks. Unlike myasthenia gravis, the recovery period is prolonged in Guillain-Barré syndrome, but often favorable, even in the more severely affected patients. Outcome, for a large part, is determined by expert neurocritical care.
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Affiliation(s)
- Maximiliano A Hawkes
- Department of Neurology, Neurocritical Care Services, Mayo Clinic, Rochester, Minnesota
| | - Eelco F M Wijdicks
- Department of Neurology, Neurocritical Care Services, Mayo Clinic, Rochester, Minnesota
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3
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Gilhus NE, Andersen H, Andersen LK, Boldingh M, Laakso S, Leopoldsdottir MO, Madsen S, Piehl F, Popperud TH, Punga AR, Schirakow L, Vissing J. Generalized myasthenia gravis with acetylcholine receptor antibodies: A guidance for treatment. Eur J Neurol 2024; 31:e16229. [PMID: 38321574 DOI: 10.1111/ene.16229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 01/16/2024] [Accepted: 01/16/2024] [Indexed: 02/08/2024]
Abstract
BACKGROUND Generalized myasthenia gravis (MG) with antibodies against the acetylcholine receptor is a chronic disease causing muscle weakness. Access to novel treatments warrants authoritative treatment recommendations. The Nordic countries have similar, comprehensive health systems, mandatory health registers, and extensive MG research. METHODS MG experts and patient representatives from the five Nordic countries formed a working group to prepare treatment guidance for MG based on a systematic literature search and consensus meetings. RESULTS Pyridostigmine represents the first-line symptomatic treatment, while ambenonium and beta adrenergic agonists are second-line options. Early thymectomy should be undertaken if a thymoma, and in non-thymoma patients up to the age of 50-65 years if not obtaining remission on symptomatic treatment. Most patients need immunosuppressive drug treatment. Combining corticosteroids at the lowest possible dose with azathioprine is recommended, rituximab being an alternative first-line option. Mycophenolate, methotrexate, and tacrolimus represent second-line immunosuppression. Plasma exchange and intravenous immunoglobulin are used for myasthenic crises and acute exacerbations. Novel complement inhibitors and FcRn blockers are effective and fast-acting treatments with promising safety profiles. Their use depends on local availability, refunding policies, and cost-benefit analyses. Adapted physical training is recommended. Planning of pregnancies with optimal treatment, information, and awareness of neonatal MG is necessary. Social support and adaptation of work and daily life activities are recommended. CONCLUSIONS Successful treatment of MG rests on timely combination of different interventions. Due to spontaneous disease fluctuations, comorbidities, and changes in life conditions, regular long-term specialized follow-up is needed. Most patients do reasonably well but there is room for further improvement. Novel treatments are promising, though subject to restricted access due to costs.
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Affiliation(s)
- Nils Erik Gilhus
- Department of Neurology, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Henning Andersen
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Linda Kahr Andersen
- Copenhagen Neuromuscular Center, Department of Neurology, Copenhagen University Hospital, Copenhagen, Denmark
| | - Marion Boldingh
- Department of Neurology, Oslo University Hospital, Oslo, Norway
| | - Sini Laakso
- Department of Neurology, Brain Center, Helsinki University Hospital, Helsinki, Finland
- Translational Immunology Research Program, University of Helsinki, Helsinki, Finland
| | | | - Sidsel Madsen
- The National Rehabilitation Center for Neuromuscular Diseases, Aarhus, Denmark
| | - Fredrik Piehl
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
| | | | - Anna Rostedt Punga
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
- Department of Clinical Neurophysiology, Uppsala University Hospital, Uppsala, Sweden
| | | | - John Vissing
- Copenhagen Neuromuscular Center, Department of Neurology, Copenhagen University Hospital, Copenhagen, Denmark
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4
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Heider D, Stetefeld H, Meisel A, Bösel J, Artho M, Linker R, Angstwurm K, Neumann B. POLAR: prediction of prolonged mechanical ventilation in patients with myasthenic crisis. J Neurol 2024; 271:2875-2879. [PMID: 38329540 PMCID: PMC11055720 DOI: 10.1007/s00415-024-12208-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 01/16/2024] [Accepted: 01/18/2024] [Indexed: 02/09/2024]
Affiliation(s)
- Dominik Heider
- Department of Machine Learning for Medical Data, Institute for Computer Science, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Germany
- Department of Data Science in Biomedicine, Faculty of Mathematics and Computer Science, University of Marburg, Marburg, Germany
| | - Henning Stetefeld
- Department of Neurology, Faculty of Medicine, University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Andreas Meisel
- Department of Neurology With Experimental Neurology, Neuroscience Clinical Research Center, Charité, Universitätsmedizin Berlin, Berlin, Germany
| | - Julian Bösel
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
- Department of Neurology, Johns Hopkins University Hospital, Baltimore, MD, USA
| | - Marie Artho
- Department of Data Science in Biomedicine, Faculty of Mathematics and Computer Science, University of Marburg, Marburg, Germany
| | - Ralf Linker
- Department of Neurology, University of Regensburg, Bezirksklinikum, Regensburg, Germany
| | - Klemens Angstwurm
- Department of Neurology, University of Regensburg, Bezirksklinikum, Regensburg, Germany
| | - Bernhard Neumann
- Department of Neurology, University of Regensburg, Bezirksklinikum, Regensburg, Germany.
- Department of Neurology, Donau-Isar-Klinikum Deggendorf, Perlasberger Straße 41, 94469, Deggendorf, Germany.
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5
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Hoffmann S, Verlohren S, Herdick M. [Myasthenia gravis-Gender aspects and family planning]. DER NERVENARZT 2024; 95:316-328. [PMID: 38499774 DOI: 10.1007/s00115-024-01640-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/23/2024] [Indexed: 03/20/2024]
Abstract
BACKGROUND There is evidence that gender-specific differences can influence the diagnostics, treatment and long-term disease course of myasthenia gravis (MG). In women the diagnosis is often made during childbearing age. OBJECTIVE Gender-specific differences in MG and relevant aspects in routine clinical practice are presented. In addition, current studies on family planning, pregnancy and childbirth in MG are highlighted and treatment recommendations are derived. MATERIAL AND METHODS Narrative literature review. RESULTS In addition to sociodemographic data, gender-specific differences encompass clinical as well as paraclinical factors, such as disease severity and antibody status. With few exceptions pregnancy is possible with good maternal and neonatal outcome. During pregnancy and peripartum, children of MG patients should be closely monitored for early detection and treatment of potential syndromes caused by diaplacental transfer of maternal antibodies. CONCLUSION Gender-specific factors can influence the course of MG. Adequate medical counselling and multidisciplinary collaboration are essential for MG patients who wish to have children.
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Affiliation(s)
- Sarah Hoffmann
- Department of Neurology, Neuroscience Clinical Research Center (NCRC) and Integrated Myasthenia Gravis Center, Charité - Universitätsmedizin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117, Berlin, Deutschland.
| | - Stefan Verlohren
- Department of Obstetrics, Charité - Universitätsmedizin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Deutschland
| | - Meret Herdick
- Department of Neurology, Neuroscience Clinical Research Center (NCRC) and Integrated Myasthenia Gravis Center, Charité - Universitätsmedizin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117, Berlin, Deutschland
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6
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Mehnert A, Bershan S, Kollmus-Heege J, Gerischer L, Herdick ML, Hoffmann S, Lehnerer S, Scheibe F, Stascheit F, Stein M, Buchan AM, Meisel A, Aigner A, Mergenthaler P. Identifying patients at risk for myasthenic crisis with hemogram and inflammation-related laboratory parameters - a pilot study. Front Neurol 2024; 15:1297997. [PMID: 38469587 PMCID: PMC10925644 DOI: 10.3389/fneur.2024.1297997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 01/29/2024] [Indexed: 03/13/2024] Open
Abstract
Background Myasthenia gravis (MG) is a rare autoimmune disease characterized by fatigable weakness of the voluntary muscles and can exacerbate to life-threatening myasthenic crisis (MC), requiring intensive care treatment. Routine laboratory parameters are a cost-effective and widely available method for estimating the clinical outcomes of several diseases, but so far, such parameters have not been established to detect disease progression in MG. Methods We conducted a retrospective analysis of selected laboratory parameters related to inflammation and hemogram for MG patients with MC compared to MG patients without MC. To identify potential risk factors for MC, we applied time-varying Cox regression for time to MC and, as a sensitivity analysis, generalized estimating equations logistic regression for the occurrence of MC at the next patient visit. Results 15 of the 58 examined MG patients suffered at least one MC. There was no notable difference in the occurrence of MC by antibody status or sex. Both regression models showed that higher counts of basophils (per 0.01 unit increase: HR = 1.32, 95% CI = 1.02-1.70), neutrophils (per 1 unit increase: HR = 1.40, 95% CI = 1.14-1.72), potentially leukocytes (per 1 unit increase: HR = 1.15, 95% CI = 0.99-1.34), and platelets (per 100 units increase: HR = 1.54, 95% CI = 0.99-2.38) may indicate increased risk for a myasthenic crisis. Conclusion This pilot study provides proof of the concept that increased counts of basophils, neutrophils, leukocytes, and platelets may be associated with a higher risk of developing MC in patients with MG.
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Affiliation(s)
- Anne Mehnert
- Charité - Universitätsmedizin Berlin, Department of Neurology with Experimental Neurology, Berlin, Germany
| | - Sivan Bershan
- Charité - Universitätsmedizin Berlin, Center for Stroke Research Berlin, Berlin, Germany
| | - Jil Kollmus-Heege
- Charité - Universitätsmedizin Berlin, Institute of Biometry and Clinical Epidemiology, Berlin, Germany
| | - Lea Gerischer
- Charité - Universitätsmedizin Berlin, Department of Neurology with Experimental Neurology, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Neuroscience Clinical Research Center, Berlin, Germany
| | - Meret Luise Herdick
- Charité - Universitätsmedizin Berlin, Department of Neurology with Experimental Neurology, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Neuroscience Clinical Research Center, Berlin, Germany
| | - Sarah Hoffmann
- Charité - Universitätsmedizin Berlin, Department of Neurology with Experimental Neurology, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Neuroscience Clinical Research Center, Berlin, Germany
| | - Sophie Lehnerer
- Charité - Universitätsmedizin Berlin, Department of Neurology with Experimental Neurology, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Neuroscience Clinical Research Center, Berlin, Germany
- Berlin Institute of Health at Charité, Digital Health Center, Berlin, Germany
| | - Franziska Scheibe
- Charité - Universitätsmedizin Berlin, Department of Neurology with Experimental Neurology, Berlin, Germany
| | - Frauke Stascheit
- Charité - Universitätsmedizin Berlin, Department of Neurology with Experimental Neurology, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Neuroscience Clinical Research Center, Berlin, Germany
| | - Maike Stein
- Charité - Universitätsmedizin Berlin, Department of Neurology with Experimental Neurology, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Neuroscience Clinical Research Center, Berlin, Germany
| | - Alastair M. Buchan
- Charité - Universitätsmedizin Berlin, Center for Stroke Research Berlin, Berlin, Germany
- Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Andreas Meisel
- Charité - Universitätsmedizin Berlin, Department of Neurology with Experimental Neurology, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Center for Stroke Research Berlin, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Neuroscience Clinical Research Center, Berlin, Germany
| | - Annette Aigner
- Charité - Universitätsmedizin Berlin, Center for Stroke Research Berlin, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Institute of Biometry and Clinical Epidemiology, Berlin, Germany
| | - Philipp Mergenthaler
- Charité - Universitätsmedizin Berlin, Department of Neurology with Experimental Neurology, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Center for Stroke Research Berlin, Berlin, Germany
- Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
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Huan X, Chen J, Zhong H, Xu Y, Wang Y, Jiang H, Song J, Yan C, Xi J, Zou Z, Zheng J, Ruan Z, Tan S, Luo L, Luo S, Zhao C. Clinical outcome and peripheral immune profile of myasthenic crisis with omicron infections: A prospective cohort study. Clin Immunol 2024; 259:109879. [PMID: 38142901 DOI: 10.1016/j.clim.2023.109879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 11/28/2023] [Accepted: 12/19/2023] [Indexed: 12/26/2023]
Abstract
The impact of Omicron infections on the clinical outcome and immune responses of myasthenia gravis (MG) remained largely unknown. From a prospective multicenter MG cohort (n = 189) with 197 myasthenic crisis (MC), we finally included 41 independent MG patients to classify into two groups: the Omicron Group (n = 13) and the Control Group (n = 28). In this matched cohort study, all-cause mortality was 7.69% (1/13) in Omicron Group and 14.29% (4/28) in Control Group. A higher proportion of elevated serum IL-6 was identified in the Omicron Group (88.89% vs 52.38%, P = 0.049). In addition, the proportions of CD3+CD8+T in lymphocytes and Tregs in CD3+CD4+ T cells were significantly elevated in the Omicron Group (both P = 0.0101). After treatment, the Omicron Group exhibited a marked improvement in MG-ADL score (P = 0.026) and MG-QoL-15 (P = 0.0357). MCs with Omicron infections were associated with elevated serum IL-6 and CD3+CD8+T response. These patients tended to present a better therapeutic response after fast-acting therapies and anti-IL-6 treatment.
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Affiliation(s)
- Xiao Huan
- Huashan Rare Disease Center and Department of Neurology, Huashan Hospital, Shanghai Medical College, National Center for Neurological Disorders, Fudan University, Shanghai 200040, China
| | - Jialin Chen
- Department of Neurology, Fujian Medical University Union Hospital, Fuzhou 350001, China
| | - Huahua Zhong
- Huashan Rare Disease Center and Department of Neurology, Huashan Hospital, Shanghai Medical College, National Center for Neurological Disorders, Fudan University, Shanghai 200040, China
| | - Yafang Xu
- Huashan Rare Disease Center and Department of Neurology, Huashan Hospital, Shanghai Medical College, National Center for Neurological Disorders, Fudan University, Shanghai 200040, China
| | - Yuan Wang
- Department of Blood Transfusion, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Haoqin Jiang
- Department of Laboratory Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Jie Song
- Huashan Rare Disease Center and Department of Neurology, Huashan Hospital, Shanghai Medical College, National Center for Neurological Disorders, Fudan University, Shanghai 200040, China
| | - Chong Yan
- Huashan Rare Disease Center and Department of Neurology, Huashan Hospital, Shanghai Medical College, National Center for Neurological Disorders, Fudan University, Shanghai 200040, China
| | - Jianying Xi
- Huashan Rare Disease Center and Department of Neurology, Huashan Hospital, Shanghai Medical College, National Center for Neurological Disorders, Fudan University, Shanghai 200040, China
| | - Zhangyu Zou
- Department of Neurology, Fujian Medical University Union Hospital, Fuzhou 350001, China
| | - Jianming Zheng
- Department of Infectious Diseases, Huashan Hospital, National Medical Center for Infectious Diseases, Fudan University, Shanghai 200040, China
| | - Zhe Ruan
- Department of Neurology, Tangdu Hospital, The Air Force Medical University, Xi'an 710000, China
| | - Song Tan
- Department of Neurology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu 610072, China
| | - Lijun Luo
- Department of Neurology, Wuhan No.1 Hospital, Wuhan 430030, China
| | - Sushan Luo
- Huashan Rare Disease Center and Department of Neurology, Huashan Hospital, Shanghai Medical College, National Center for Neurological Disorders, Fudan University, Shanghai 200040, China.
| | - Chongbo Zhao
- Huashan Rare Disease Center and Department of Neurology, Huashan Hospital, Shanghai Medical College, National Center for Neurological Disorders, Fudan University, Shanghai 200040, China.
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Habib AA, Sacks N, Cool C, Durgapal S, Dennen S, Everson K, Hughes T, Hernandez J, Phillips G. Hospitalizations and Mortality From Myasthenia Gravis: Trends From 2 US National Datasets. Neurology 2024; 102:e207863. [PMID: 38165317 DOI: 10.1212/wnl.0000000000207863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 10/03/2023] [Indexed: 01/03/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Myasthenia gravis (MG) is a rare neuromuscular disorder where IgG antibodies damage the communication between nerves and muscles, leading to muscle weakness that can be severe and have a significant impact on patients' lives. MG exacerbations include myasthenic crisis with respiratory failure, the most serious manifestation of MG. Recent studies have found MG prevalence increasing, especially in older patients. This study examined trends in hospital admissions and in-hospital mortality for adult patients with MG and readmissions and postdischarge mortality in older (65 years or older) adults with MG. METHODS Data from the Nationwide Inpatient Sample (NIS), an all-payer national database of hospital discharges, were used to characterize trends in hospitalizations and in-hospital mortality related to MG exacerbations and MG crisis among adult patients aged 18 years or older. The Medicare Limited Data Set, a deidentified, longitudinal research database with demographic, enrollment, and claims data was used to assess hospitalizations, length of stay (LOS), readmissions, and 30-day postdischarge mortality among fee-for-service Medicare beneficiaries aged 65 years or older. The study period was 2010-2019. Multinomial logit models and Poisson regression were used to test for significance of trends. RESULTS Hospitalization rates for 19,715 unique adult patients and 56,822 admissions increased from 2010 to 2019 at an average annualized rate of 4.9% (MG noncrisis: 4.4%; MG crisis: 6.8%; all p < 0.001). Readmission rates were approximately 20% in each study year for both crisis and noncrisis hospitalizations; the in-hospital mortality rate averaged 1.8%. Among patients aged 65 years or older, annualized increases in hospitalizations were estimated at 5.2%, 4.2%, and 7.7% for all, noncrisis, and crisis hospitalizations, respectively (all p < 0.001). The average LOS was stable over the study period, ranging from 11.3 to 13.1 days, but was consistently longer for MG crisis admissions. Mortality among patients aged 65 years or older was higher compared with that in all patients, averaging 5.0% across each of the study years. DISCUSSION Increasing hospitalization rates suggest a growing burden associated with MG, especially among older adults. While readmission and mortality rates have remained stable, the increasing hospitalization rates indicate that the raw numbers of readmissions-and deaths-are also increasing. Mortality rates are considerably higher in older patients hospitalized with MG.
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Affiliation(s)
- Ali A Habib
- From the University of California (A.A.H.), Irvine; Precision Health Economics and Outcomes Research (N.S., C.C., S. Durgapal, S. Dennen, K.E., J.H.), New York, NY; Argenx (T.H., G.P.), Ghent, Belgium
| | - Naomi Sacks
- From the University of California (A.A.H.), Irvine; Precision Health Economics and Outcomes Research (N.S., C.C., S. Durgapal, S. Dennen, K.E., J.H.), New York, NY; Argenx (T.H., G.P.), Ghent, Belgium
| | - Christina Cool
- From the University of California (A.A.H.), Irvine; Precision Health Economics and Outcomes Research (N.S., C.C., S. Durgapal, S. Dennen, K.E., J.H.), New York, NY; Argenx (T.H., G.P.), Ghent, Belgium
| | - Sneha Durgapal
- From the University of California (A.A.H.), Irvine; Precision Health Economics and Outcomes Research (N.S., C.C., S. Durgapal, S. Dennen, K.E., J.H.), New York, NY; Argenx (T.H., G.P.), Ghent, Belgium
| | - Syvart Dennen
- From the University of California (A.A.H.), Irvine; Precision Health Economics and Outcomes Research (N.S., C.C., S. Durgapal, S. Dennen, K.E., J.H.), New York, NY; Argenx (T.H., G.P.), Ghent, Belgium
| | - Katie Everson
- From the University of California (A.A.H.), Irvine; Precision Health Economics and Outcomes Research (N.S., C.C., S. Durgapal, S. Dennen, K.E., J.H.), New York, NY; Argenx (T.H., G.P.), Ghent, Belgium
| | - Tom Hughes
- From the University of California (A.A.H.), Irvine; Precision Health Economics and Outcomes Research (N.S., C.C., S. Durgapal, S. Dennen, K.E., J.H.), New York, NY; Argenx (T.H., G.P.), Ghent, Belgium
| | - Jennifer Hernandez
- From the University of California (A.A.H.), Irvine; Precision Health Economics and Outcomes Research (N.S., C.C., S. Durgapal, S. Dennen, K.E., J.H.), New York, NY; Argenx (T.H., G.P.), Ghent, Belgium
| | - Glenn Phillips
- From the University of California (A.A.H.), Irvine; Precision Health Economics and Outcomes Research (N.S., C.C., S. Durgapal, S. Dennen, K.E., J.H.), New York, NY; Argenx (T.H., G.P.), Ghent, Belgium
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Watanabe K, Ohashi S, Watanabe T, Kakinuma Y, Kinno R. Case report: Recovery from refractory myasthenic crisis to minimal symptom expression after add-on treatment with efgartigimod. Front Neurol 2024; 15:1321058. [PMID: 38318438 PMCID: PMC10838969 DOI: 10.3389/fneur.2024.1321058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 01/08/2024] [Indexed: 02/07/2024] Open
Abstract
Myasthenic crisis, a life-threatening exacerbation of myasthenia gravis, is a significant clinical challenge, particularly when refractory to standard therapies. Here, we described a case of myasthenic crisis in which the patient transitioned from refractory myasthenic crisis to minimal symptom expression after receiving add-on treatment with efgartigimod, a novel neonatal Fc receptor antagonist. A 54 years-old woman who was diagnosed with anti-acetylcholine receptor antibody-positive myasthenia gravis experienced respiratory failure necessitating mechanical ventilation. Despite aggressive treatment with plasmapheresis, intravenous immunoglobulins, and high-dose corticosteroids, her condition continued to deteriorate, culminating in persistent myasthenic crisis. Efgartigimod was administered as salvage therapy. Remarkable improvement in neuromuscular function was observed within days, allowing for successful weaning from mechanical ventilation. Over the subsequent weeks, the patient's symptoms continued to ameliorate, ultimately reaching a state of minimal symptom expression. Serial assessments of her serum anti-acetylcholine receptor antibody titer showed a consistent decline in parallel with this clinical improvement. This case highlights efgartigimod's potential as an effective therapeutic option for refractory myasthenic crisis, offering new hope for patients facing this life-threatening condition.
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Affiliation(s)
- Keiko Watanabe
- Division of Neurology, Department of Internal Medicine, Showa University Northern Yokohama Hospital, Yokohama, Japan
| | - Shinichi Ohashi
- Respiratory Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Japan
| | - Takuya Watanabe
- Division of Neurology, Department of Internal Medicine, Showa University Northern Yokohama Hospital, Yokohama, Japan
| | - Yuki Kakinuma
- Division of Neurology, Department of Internal Medicine, Showa University Northern Yokohama Hospital, Yokohama, Japan
| | - Ryuta Kinno
- Division of Neurology, Department of Internal Medicine, Showa University Northern Yokohama Hospital, Yokohama, Japan
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10
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Neumann B, Angstwurm K, Dohmen C, Mergenthaler P, Kohler S, Schönenberger S, Lee DH, Gerner ST, Huttner HB, Thieme A, Steinbrecher A, Dunkel J, Roth C, Schneider H, Reichmann H, Fuhrer H, Kleiter I, Schneider-Gold C, Alberty A, Zinke J, Schroeter M, Linker R, Meisel A, Bösel J, Stetefeld HR. Weaning and extubation failure in myasthenic crisis: a multicenter analysis. J Neurol 2024; 271:564-574. [PMID: 37923937 DOI: 10.1007/s00415-023-12016-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 09/18/2023] [Accepted: 09/19/2023] [Indexed: 11/06/2023]
Abstract
Myasthenic crisis (MC) requiring mechanical ventilation is a serious complication of myasthenia gravis (MG). Here we analyze the frequency and risk factors of weaning- and extubation failure as well as its impact on the clinical course in a large cohort. We performed a retrospective chart review on patients treated for MC in 12 German neurological departments between 2006 and 2015. Weaning failure (WF) was defined as negative spontaneous breathing trial, primary tracheostomy, or extubation failure (EF) (reintubation or death). WF occurred in 138 episodes (64.2%). Older Age (p = 0.039), multiple comorbidities (≥ 3) (p = 0.007, OR = 4.04), late-onset MG (p = 0.004, OR = 2.84), complications like atelectasis (p = 0.008, OR = 3.40), pneumonia (p < 0.0001, OR = 3.45), cardio-pulmonary resuscitation (p = 0.005, OR = 5.00) and sepsis (p = 0.02, OR = 2.57) were associated with WF. WF occurred often in patients treated with intravenous immungloblins (IVIG) (p = 0.002, OR = 2.53), whereas WF was less often under first-line therapy with plasma exchange or immunoadsorption (p = 0.07, OR = 0.57). EF was observed in 58 of 135 episodes (43.0%) after first extubation attempt and was related with prolonged mechanical ventilation, intensive care unit stay and hospital stay (p ≤ 0.0001 for all). Extubation success was most likely in a time window for extubation between day 7 and 12 after intubation (p = 0.06, OR = 2.12). We conclude that WF and EF occur very often in MC and are associated with poor outcome. Older age, multiple comorbidities and development of cardiac and pulmonary complications are associated with a higher risk of WF and EF. Our data suggest that WF occurs less frequently under first-line plasma exchange/immunoadsorption compared with first-line use of IVIG.
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Affiliation(s)
- Bernhard Neumann
- Department of Neurology, Donau-Isar-Klinikum Deggendorf, Deggendorf, Germany
- Department of Neurology, University Medical Center Regensburg, Regensburg, Germany
| | - Klemens Angstwurm
- Department of Neurology, University Medical Center Regensburg, Regensburg, Germany
| | - Christian Dohmen
- Department of Neurology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
- Department for Neurology and Neurological Intensive Care Medicine, LVR-Klinik Bonn, Bonn, Germany
| | - Philipp Mergenthaler
- NeuroCure Clinical Research Center, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Department of Neurology with Experimental Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Charité-Universitätsmedizin Berlin, Center for Stroke Research Berlin, Berlin, Germany
| | - Siegfried Kohler
- NeuroCure Clinical Research Center, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Charité-Universitätsmedizin Berlin, Center for Stroke Research Berlin, Berlin, Germany
- Department of Neurology, Sana Klinikum Landkreis Biberach, Biberach, Germany
| | | | - De-Hyung Lee
- Department of Neurology, University Medical Center Regensburg, Regensburg, Germany
- Department of Neurology, University Hospital Erlangen, Erlangen, Germany
| | - Stefan T Gerner
- Department of Neurology, University Hospital Erlangen, Erlangen, Germany
- Department of Neurology, Universitätsklinikum Gießen Und Marburg, Gießen, Germany
| | - Hagen B Huttner
- Department of Neurology, University Hospital Erlangen, Erlangen, Germany
- Department of Neurology, Universitätsklinikum Gießen Und Marburg, Gießen, Germany
| | - Andrea Thieme
- Department of Neurology, HELIOS Klinikum Erfurt, Erfurt, Germany
| | | | - Juliane Dunkel
- Department of Neurology, DRK-Kliniken Nordhessen, Kassel, Germany
| | - Christian Roth
- Department of Neurology, DRK-Kliniken Nordhessen, Kassel, Germany
- Department of Neurology, Kassel General Hospital, Kassel, Germany
| | - Hauke Schneider
- Department of Neurology, University Hospital, Technische Universität Dresden, Dresden, Germany
- Department of Neurology, University Hospital Augsburg, Augsburg, Germany
| | - Heinz Reichmann
- Department of Neurology, University Hospital, Technische Universität Dresden, Dresden, Germany
| | - Hannah Fuhrer
- Department of Neurology, Medical Center-University of Freiburg, Freiburg, Germany
- Department of Neurology, HELIOS Klinik Mühlheim, Mühlheim, Germany
| | - Ingo Kleiter
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany
- Marianne-Strauß-Klinik, Behandlungszentrum Kempfenhausen für Multiple Sklerose Kranke gGmbH, Berg, Germany
| | | | - Anke Alberty
- Department of Neurology, Kliniken Maria Hilf GmbH Moenchengladbach, Moenchengladbach, Germany
| | - Jan Zinke
- Hans Berger Department of Neurology, Jena University Hospital, Jena, Germany
| | - Michael Schroeter
- Department of Neurology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Ralf Linker
- Department of Neurology, University Medical Center Regensburg, Regensburg, Germany
| | - Andreas Meisel
- NeuroCure Clinical Research Center, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Department of Neurology with Experimental Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Charité-Universitätsmedizin Berlin, Center for Stroke Research Berlin, Berlin, Germany
| | - Julian Bösel
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Henning R Stetefeld
- Department of Neurology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany.
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11
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Mihalache OA, Vilciu C, Petrescu DM, Petrescu C, Manea MC, Ciobanu AM, Ciobanu CA, Popa-Velea O, Riga S. Depression: A Contributing Factor to the Clinical Course in Myasthenia Gravis Patients. MEDICINA (KAUNAS, LITHUANIA) 2023; 60:56. [PMID: 38256317 PMCID: PMC10819146 DOI: 10.3390/medicina60010056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Revised: 12/22/2023] [Accepted: 12/26/2023] [Indexed: 01/24/2024]
Abstract
Background and Objectives: The association between myasthenia gravis (MG) and depression is intricate and characterized by bidirectional causality. In this regard, MG can be a contributing factor to depression and, conversely, depression may worsen the symptoms of MG. This study aimed to identify any differences in the progression of the disease among patients with MG who were also diagnosed with depression as compared to those without depression. Our hypothesis focused on the theory that patients with more severe MG symptoms may have a higher likelihood of suffering depression at the same time. Materials and Methods: One hundred twenty-two male and female patients (N = 122) aged over 18 with a confirmed diagnosis of autoimmune MG who were admitted to the Neurology II department of Myasthenia Gravis, Clinical Institute Fundeni in Bucharest between January 2019 and December 2020, were included in the study. Patients were assessed at baseline and after six months. The psychiatric assessment of the patients included the Hamilton Depression Rating Scale-17 items (HAM-D), and neurological status was determined with two outcome measures: Quantitative Myasthenia Gravis (QMG) and Myasthenia Gravis Activities of Daily Life (MG-ADL). The patients were divided into two distinct groups as follows: group MG w/dep, which comprised 49 MG patients diagnosed with depressive disorder who were also currently receiving antidepressant medication, and group MG w/o dep, which consisted of 73 patients who did not have depression. Results: In our study, 40.16% of the myasthenia gravis (MG) patients exhibited a comorbid diagnosis of depression. Among the MG patients receiving antidepressant treatment, baseline assessments revealed a mean MG-ADL score of 7.73 (SD = 5.05), an average QMG score of 18.40 (SD = 8.61), and a mean Ham-D score of 21.53 (SD = 7.49). After a six-month period, a statistically significant decrease was observed in the MG-ADL (2.92, SD = 1.82), QMG (7.15, SD = 4.46), and Ham-D scores (11.16, SD = 7.49) (p < 0.0001). These results suggest a significant correlation between MG severity and elevated HAM-D depression scores. Regarding the MG treatment in the group with depression, at baseline, the mean dose of oral corticosteroids was 45.10 mg (SD = 16.60). Regarding the treatment with pyridostigmine, patients with depression and undergoing antidepressant treatment remained with an increased need for pyridostigmine, 144.49 mg (SD = 51.84), compared to those in the group without depression, 107.67 mg (SD = 55.64, p < 0.001). Conclusions: Our investigation confirms that the occurrence of depressive symptoms is significantly widespread among individuals diagnosed with MG. Disease severity, along with younger age and higher doses of cortisone, is a significant factor associated with depression in patients with MG. Substantial reductions in MG-ADL and QMG scores were observed within each group after six months, highlighting the effectiveness of MG management. The findings suggest that addressing depressive symptoms in MG patients, in addition to standard MG management, can lead to improved clinical outcomes.
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Affiliation(s)
- Oana Antonia Mihalache
- Department of Doctoral Studies, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania;
- Department of Neurology, “Fundeni” Clinical Institute, 022328 Bucharest, Romania;
| | - Crisanda Vilciu
- Department of Neurology, “Fundeni” Clinical Institute, 022328 Bucharest, Romania;
- Department of Neurology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania;
| | - Diana-Mihaela Petrescu
- Department of Neurology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania;
| | - Cristian Petrescu
- Department of Psychiatry, “Prof. Dr. Alexandru Obregia” Clinical Hospital of Psychiatry, 041914 Bucharest, Romania; (C.P.); (M.C.M.)
- Neuroscience Department, Discipline of Psychiatry, Faculty of Medicine, University of Medicine and Pharmacy “Carol Davila”, 020021 Bucharest, Romania
| | - Mihnea Costin Manea
- Department of Psychiatry, “Prof. Dr. Alexandru Obregia” Clinical Hospital of Psychiatry, 041914 Bucharest, Romania; (C.P.); (M.C.M.)
- Neuroscience Department, Discipline of Psychiatry, Faculty of Medicine, University of Medicine and Pharmacy “Carol Davila”, 020021 Bucharest, Romania
| | - Adela Magdalena Ciobanu
- Department of Psychiatry, “Prof. Dr. Alexandru Obregia” Clinical Hospital of Psychiatry, 041914 Bucharest, Romania; (C.P.); (M.C.M.)
- Neuroscience Department, Discipline of Psychiatry, Faculty of Medicine, University of Medicine and Pharmacy “Carol Davila”, 020021 Bucharest, Romania
| | | | - Ovidiu Popa-Velea
- Department of Medical Psychology, Faculty of Medicine, University of Medicine and Pharmacy “Carol Davila”, 050474 Bucharest, Romania;
| | - Sorin Riga
- Department of Stress Research and Prophylaxis, “Prof. Dr. Alexandru Obregia” Clinical Hospital of Psychiatry, 041914 Bucharest, Romania;
- Romanian Academy of Medical Sciences, 927180 Bucharest, Romania
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12
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Balistreri CR, Monastero R. Neuroinflammation and Neurodegenerative Diseases: How Much Do We Still Not Know? Brain Sci 2023; 14:19. [PMID: 38248234 PMCID: PMC10812964 DOI: 10.3390/brainsci14010019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 12/12/2023] [Accepted: 12/21/2023] [Indexed: 01/23/2024] Open
Abstract
The term "neuroinflammation" defines the typical inflammatory response of the brain closely related to the onset of many neurodegenerative diseases (NDs). Neuroinflammation is well known, but its mechanisms and pathways are not entirely comprehended. Some progresses have been achieved through many efforts and research. Consequently, new cellular and molecular mechanisms, diverse and conventional, are emerging. In listing some of those that will be the subject of our description and discussion, essential are the important roles of peripheral and infiltrated monocytes and clonotypic cells, alterations in the gut-brain axis, dysregulation of the apelinergic system, alterations in the endothelial glycocalyx of the endothelial component of neuronal vascular units, variations in expression of some genes and levels of the encoding molecules by the action of microRNAs (miRNAs), or other epigenetic factors and distinctive transcriptional factors, as well as the role of autophagy, ferroptosis, sex differences, and modifications in the circadian cycle. Such mechanisms can add significantly to understanding the complex etiological puzzle of neuroinflammation and ND. In addition, they could represent biomarkers and targets of ND, which is increasing in the elderly.
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Affiliation(s)
- Carmela Rita Balistreri
- Cellular and Molecular Laboratory, Department of Biomedicine, Neuroscience and Advanced Diagnostics (Bi.N.D.), University of Palermo, 90134 Palermo, Italy
| | - Roberto Monastero
- Unit of Neurology & Neuro-Physiopathology, Department of Biomedicine, Neuroscience, and Advanced Diagnostics (Bi.N.D), University of Palermo, Via La Loggia 1, 90129 Palermo, Italy;
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13
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Krall JTW, Chakravartty A, Caress JB, Files DC. Identification and Management of Acute Neuromuscular Respiratory Failure in the ICU. Chest 2023; 164:1454-1461. [PMID: 38070961 DOI: 10.1016/j.chest.2023.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 08/22/2023] [Accepted: 09/12/2023] [Indexed: 12/18/2023] Open
Abstract
Respiratory failure is a common and potentially life-threatening complication of neuromuscular diseases. Prompt recognition and accurate diagnosis of new or worsening chronic neuromuscular disease have important clinical management and prognostic implications. In this article, we present an approach to the acute presentation of undifferentiated neuromuscular respiratory failure in the ICU and guidance for determination and respiratory management of the underlying disorder.
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Affiliation(s)
- Jennifer T W Krall
- Department of Internal Medicine, Section on Pulmonary, Critical Care, Allergy, and Immunologic Diseases, Wake Forest University School of Medicine, Winston-Salem, NC.
| | - Akash Chakravartty
- Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, NC
| | - James B Caress
- Department of Neurology, Wake Forest University School of Medicine, Winston-Salem, NC
| | - D Clark Files
- Department of Internal Medicine, Section on Pulmonary, Critical Care, Allergy, and Immunologic Diseases, Wake Forest University School of Medicine, Winston-Salem, NC
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14
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Westhoff M, Neumann P, Geiseler J, Bickenbach J, Arzt M, Bachmann M, Braune S, Delis S, Dellweg D, Dreher M, Dubb R, Fuchs H, Hämäläinen N, Heppner H, Kluge S, Kochanek M, Lepper PM, Meyer FJ, Neumann B, Putensen C, Schimandl D, Schönhofer B, Schreiter D, Walterspacher S, Windisch W. [Non-invasive Mechanical Ventilation in Acute Respiratory Failure. Clinical Practice Guidelines - on behalf of the German Society of Pneumology and Ventilatory Medicine]. Pneumologie 2023. [PMID: 37832578 DOI: 10.1055/a-2148-3323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2023]
Abstract
The guideline update outlines the advantages as well as the limitations of NIV in the treatment of acute respiratory failure in daily clinical practice and in different indications.Non-invasive ventilation (NIV) has a high value in therapy of hypercapnic acute respiratory failure, as it significantly reduces the length of ICU stay and hospitalization as well as mortality.Patients with cardiopulmonary edema and acute respiratory failure should be treated with continuous positive airway pressure (CPAP) and oxygen in addition to necessary cardiological interventions. This should be done already prehospital and in the emergency department.In case of other forms of acute hypoxaemic respiratory failure with only mild or moderately disturbed gas exchange (PaO2/FiO2 > 150 mmHg) there is no significant advantage or disadvantage compared to high flow nasal oxygen (HFNO). In severe forms of ARDS NIV is associated with high rates of treatment failure and mortality, especially in cases with NIV-failure and delayed intubation.NIV should be used for preoxygenation before intubation. In patients at risk, NIV is recommended to reduce extubation failure. In the weaning process from invasive ventilation NIV essentially reduces the risk of reintubation in hypercapnic patients. NIV is regarded useful within palliative care for reduction of dyspnea and improving quality of life, but here in concurrence to HFNO, which is regarded as more comfortable. Meanwhile NIV is also recommended in prehospital setting, especially in hypercapnic respiratory failure and pulmonary edema.With appropriate monitoring in an intensive care unit NIV can also be successfully applied in pediatric patients with acute respiratory insufficiency.
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Affiliation(s)
- Michael Westhoff
- Klinik für Pneumologie, Lungenklinik Hemer - Zentrum für Pneumologie und Thoraxchirurgie, Hemer
| | - Peter Neumann
- Abteilung für Klinische Anästhesiologie und Operative Intensivmedizin, Evangelisches Krankenhaus Göttingen-Weende gGmbH
| | - Jens Geiseler
- Medizinische Klinik IV - Pneumologie, Beatmungs- und Schlafmedizin, Paracelsus-Klinik Marl, Marl
| | - Johannes Bickenbach
- Klinik für Operative Intensivmedizin und Intermediate Care, Uniklinik RWTH Aachen, Aachen
| | - Michael Arzt
- Schlafmedizinisches Zentrum der Klinik und Poliklinik für Innere Medizin II, Universitätsklinikum Regensburg, Regensburg
| | - Martin Bachmann
- Klinik für Atemwegs-, Lungen- und Thoraxmedizin, Beatmungszentrum Hamburg-Harburg, Asklepios Klinikum Harburg, Hamburg
| | - Stephan Braune
- IV. Medizinische Klinik: Akut-, Notfall- und Intensivmedizin, St. Franziskus-Hospital, Münster
| | - Sandra Delis
- Klinik für Pneumologie, Palliativmedizin und Geriatrie, Helios Klinikum Emil von Behring GmbH, Berlin
| | - Dominic Dellweg
- Klinik für Innere Medizin, Pneumologie und Gastroenterologie, Pius-Hospital Oldenburg, Universitätsmedizin Oldenburg
| | - Michael Dreher
- Klinik für Pneumologie und Internistische Intensivmedizin, Uniklinik RWTH Aachen
| | - Rolf Dubb
- Akademie der Kreiskliniken Reutlingen GmbH, Reutlingen
| | - Hans Fuchs
- Zentrum für Kinder- und Jugendmedizin, Neonatologie und pädiatrische Intensivmedizin, Universitätsklinikum Freiburg
| | | | - Hans Heppner
- Klinik für Geriatrie und Geriatrische Tagesklinik Klinikum Bayreuth, Medizincampus Oberfranken Friedrich-Alexander-Universität Erlangen-Nürnberg, Bayreuth
| | - Stefan Kluge
- Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg
| | - Matthias Kochanek
- Klinik I für Innere Medizin, Hämatologie und Onkologie, Universitätsklinikum Köln, Köln
| | - Philipp M Lepper
- Klinik für Innere Medizin V - Pneumologie, Allergologie und Intensivmedizin, Universitätsklinikum des Saarlandes und Medizinische Fakultät der Universität des Saarlandes, Homburg
| | - F Joachim Meyer
- Lungenzentrum München - Bogenhausen-Harlaching) München Klinik gGmbH, München
| | - Bernhard Neumann
- Klinik für Neurologie, Donauisar Klinikum Deggendorf, und Klinik für Neurologie der Universitätsklinik Regensburg am BKH Regensburg, Regensburg
| | - Christian Putensen
- Klinik und Poliklinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Bonn, Bonn
| | - Dorit Schimandl
- Klinik für Pneumologie, Beatmungszentrum, Zentralklinik Bad Berka GmbH, Bad Berka
| | - Bernd Schönhofer
- Klinik für Innere Medizin, Pneumologie und Intensivmedizin, Evangelisches Klinikum Bethel, Universitätsklinikum Ost Westphalen-Lippe, Bielefeld
| | | | - Stephan Walterspacher
- Medizinische Klinik - Sektion Pneumologie, Klinikum Konstanz und Lehrstuhl für Pneumologie, Universität Witten-Herdecke, Witten
| | - Wolfram Windisch
- Lungenklinik, Kliniken der Stadt Köln gGmbH, Lehrstuhl für Pneumologie Universität Witten/Herdecke, Köln
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15
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Huan X, Ruan Z, Zhao R, Su M, Ning F, Zou Z, Tan S, Luo L, Yang S, Shi J, Liu Y, Jiang Q, Xi J, Chang T, Luo S, Zhao C. Myasthenic crisis in thymoma-associated myasthenia gravis: a multicenter retrospective cohort study. Neuromuscul Disord 2023; 33:782-787. [PMID: 37783628 DOI: 10.1016/j.nmd.2023.09.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 08/03/2023] [Accepted: 09/19/2023] [Indexed: 10/04/2023]
Abstract
Thymoma-associated myasthenia gravis (TMG) had more severe symptoms and worse prognoses in comparison to non-thymoma-associated MG. Thymoma recurrence was frequently associated with transient worsening of MG and even acute respiratory failure, namely myasthenic crisis (MC). However, little is known about the clinical features and outcomes of MC in thymoma-associated MG patients. We performed a retrospective cohort study in MG patients recruited from 9 independent tertiary neuromuscular centers in China from Jan 2015, through Oct 2022. Overall, 156 MC from 149 MG patients with positive anti-acetylcholine receptor (AChR) antibodies were finally analyzed. Next, these patients were divided into two subgroups: the TMG group (n = 60 MCs, 58 patients) and the non-thymoma-associated MG group (n = 96 MCs, 91 patients). Compared with non-thymoma-associated MG, TMG patients had a significantly shorter disease duration from symptom onset to the crisis (17.95±40.9 vs 51.31±60.61 months, P<0.0001), a larger proportion of MGFA IVa as the initial onset clinical classification (6.67% vs 0, P = 0.0205), and a longer hospital stay (39.24±22.09 [6-111] vs. 33.2 ± 23.42 days [7-120]; P = 0.0317) during the crisis. Within the TMG group, the hospital stay was significantly longer in patients with unresected thymoma compared to that in postoperative myasthenic crisis (POMC) (47.68±24.9 [6-111] vs. 34.21±18.87 days [12-82]; P = 0.0257). Early identification of the MG categories may provide some hints in tailoring therapeutic strategies to improve the prognosis.
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Affiliation(s)
- Xiao Huan
- Huashan Rare disease center, Department of Neurology, Huashan Hospital Fudan University, Shanghai 200040, China; National Center for Neurological Disorders, Shanghai 200040, China
| | - Zhe Ruan
- Department of Neurology, Tangdu Hospital, The Air Force Medical University, Xi'an 710000, China
| | - Rui Zhao
- Huashan Rare disease center, Department of Neurology, Huashan Hospital Fudan University, Shanghai 200040, China; National Center for Neurological Disorders, Shanghai 200040, China
| | - Manqiqige Su
- Huashan Rare disease center, Department of Neurology, Huashan Hospital Fudan University, Shanghai 200040, China; National Center for Neurological Disorders, Shanghai 200040, China
| | - Fan Ning
- Department of Neurology, Tangdu Hospital, The Air Force Medical University, Xi'an 710000, China
| | - Zhangyu Zou
- Department of Neurology, Fujian Medical University Union Hospital, Institute of Clinical Neurology, Fujian Medical University, Fuzhou 350001, China
| | - Song Tan
- Department of Neurology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu 610072, China
| | - Lijun Luo
- Department of Neurology, Wuhan No.1 Hospital, Wuhan 430030, China
| | - Song Yang
- Department of Neurology, The First People's Hospital of Changzhou, Third Affiliated Hospital of Soochow University, Changzhou 213003, China
| | - Jianquan Shi
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing 210006, China
| | - Yanping Liu
- Department of Neurology, Zhongnan Hospital of Wuhan University, Wuhan 430071, China
| | - Qilong Jiang
- Department of Neurology, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou 510405, China
| | - Jianying Xi
- Huashan Rare disease center, Department of Neurology, Huashan Hospital Fudan University, Shanghai 200040, China; National Center for Neurological Disorders, Shanghai 200040, China
| | - Ting Chang
- Department of Neurology, Tangdu Hospital, The Air Force Medical University, Xi'an 710000, China
| | - Sushan Luo
- Huashan Rare disease center, Department of Neurology, Huashan Hospital Fudan University, Shanghai 200040, China; National Center for Neurological Disorders, Shanghai 200040, China.
| | - Chongbo Zhao
- Huashan Rare disease center, Department of Neurology, Huashan Hospital Fudan University, Shanghai 200040, China; National Center for Neurological Disorders, Shanghai 200040, China.
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16
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Almodovar JL, Mehrabyan A. Disease-Based Prognostication: Myasthenia Gravis. Semin Neurol 2023; 43:799-806. [PMID: 37751854 DOI: 10.1055/s-0043-1775791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/28/2023]
Abstract
Myasthenia gravis (MG) is an acquired autoimmune neuromuscular junction transmission disorder that clinically presents as fluctuating or persistent weakness in various skeletal muscle groups. Neuroprognostication in MG begins with some basic observations on the natural history of the disease and known treatment outcomes. Our objective is to provide a framework that can assist a clinician who encounters the MG patient for the first time and attempts to prognosticate probable outcomes in individual patients. In this review article, we explore clinical type, age of onset, antibody status, severity of disease, thymus pathology, autoimmune, and other comorbidities as prognostic factors in MG.
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Affiliation(s)
- Jorge L Almodovar
- Department of Neurology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Anahit Mehrabyan
- Department of Neurology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
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17
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Zhong H, Huan X, Zhao R, Su M, Yan C, Song J, Xi J, Zhao C, Luo F, Luo S. Peripheral immune landscape for hypercytokinemia in myasthenic crisis utilizing single-cell transcriptomics. J Transl Med 2023; 21:564. [PMID: 37620910 PMCID: PMC10464341 DOI: 10.1186/s12967-023-04421-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 08/07/2023] [Indexed: 08/26/2023] Open
Abstract
BACKGROUND Myasthenia gravis (MG) is the most prevalent autoimmune disorder affecting the neuromuscular junction. A rapid deterioration in respiratory muscle can lead to a myasthenic crisis (MC), which represents a life-threatening condition with high mortality in MG. Multiple CD4+ T subsets and hypercytokinemia have been identified in the peripheral pro-inflammatory milieu during the crisis. However, the pathogenesis is complicated due to the many types of cells involved, leaving the underlying mechanism largely unexplored. METHODS We conducted single-cell transcriptomic and immune repertoire sequencing on 33,577 peripheral blood mononuclear cells (PBMCs) from two acetylcholine receptor antibody-positive (AChR +) MG patients during MC and again three months post-MC. We followed the Scanpy workflow for quality control, dimension reduction, and clustering of the single-cell data. Subsequently, we annotated high-resolution cell types utilizing transfer-learning models derived from publicly available single-cell immune datasets. RNA velocity calculations from unspliced and spliced mRNAs were applied to infer cellular state progression. We analyzed cell communication and MG-relevant cytokines and chemokines to identify potential inflammation initiators. RESULTS We identified a unique subset of monocytes, termed monocytes 3 (FCGR3B+ monocytes), which exhibited significant differential expression of pro-inflammatory signaling pathways during and after the crisis. In line with the activated innate immune state indicated by MC, a high neutrophil-lymphocyte ratio (NLR) was confirmed in an additional 22 AChR + MC patients in subsequent hemogram analysis and was associated with MG-relevant clinical scores. Furthermore, oligoclonal expansions were identified in age-associated B cells exhibiting high autoimmune activity, and in CD4+ and CD8+ T cells demonstrating persistent T exhaustion. CONCLUSIONS In summary, our integrated analysis of single-cell transcriptomics and TCR/BCR sequencing has underscored the role of innate immune activation which is associated with hypercytokinemia in MC. The identification of a specific monocyte cluster that dominates the peripheral immune profile may provide some hints into the etiology and pathology of MC. However, future functional studies are required to explore causality.
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Affiliation(s)
- Huahua Zhong
- Huashan Rare Disease Center and Department of Neurology, Huashan Hospital, Shanghai Medical College, National Center for Neurological Disorders, Fudan University, Shanghai, 200040, China
| | - Xiao Huan
- Huashan Rare Disease Center and Department of Neurology, Huashan Hospital, Shanghai Medical College, National Center for Neurological Disorders, Fudan University, Shanghai, 200040, China
| | - Rui Zhao
- Huashan Rare Disease Center and Department of Neurology, Huashan Hospital, Shanghai Medical College, National Center for Neurological Disorders, Fudan University, Shanghai, 200040, China
| | - Manqiqige Su
- Huashan Rare Disease Center and Department of Neurology, Huashan Hospital, Shanghai Medical College, National Center for Neurological Disorders, Fudan University, Shanghai, 200040, China
| | - Chong Yan
- Huashan Rare Disease Center and Department of Neurology, Huashan Hospital, Shanghai Medical College, National Center for Neurological Disorders, Fudan University, Shanghai, 200040, China
| | - Jie Song
- Huashan Rare Disease Center and Department of Neurology, Huashan Hospital, Shanghai Medical College, National Center for Neurological Disorders, Fudan University, Shanghai, 200040, China
| | - Jianying Xi
- Huashan Rare Disease Center and Department of Neurology, Huashan Hospital, Shanghai Medical College, National Center for Neurological Disorders, Fudan University, Shanghai, 200040, China
| | - Chongbo Zhao
- Huashan Rare Disease Center and Department of Neurology, Huashan Hospital, Shanghai Medical College, National Center for Neurological Disorders, Fudan University, Shanghai, 200040, China
| | - Feifei Luo
- Department of Digestive Diseases, Huashan Hospital, Fudan University, Shanghai, 200040, China.
| | - Sushan Luo
- Huashan Rare Disease Center and Department of Neurology, Huashan Hospital, Shanghai Medical College, National Center for Neurological Disorders, Fudan University, Shanghai, 200040, China.
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18
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Morar R, Seedat F, Richards GA. Clinical features and outcomes of patients with myasthenia gravis admitted to an intensive care unit: A 20-year retrospective study. SOUTHERN AFRICAN JOURNAL OF CRITICAL CARE 2023; 39:10.7196/SAJCC.2023.v39i2.561. [PMID: 37547769 PMCID: PMC10399547 DOI: 10.7196/sajcc.2023.v39i2.561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 05/28/2023] [Indexed: 08/08/2023] Open
Abstract
Background There are limited data on the clinical characteristics and outcomes of patients with myasthenia gravis (MG) admitted to the intensive care unit (ICU) at Charlotte Maxeke Johannesburg Academic Hospital (CMJAH). Objectives The aim was to study the clinical characteristics and outcomes of patients with MG admitted to the CMJAH over two decades. Methods A retrospective study was undertaken of patients with MG admitted to the multidisciplinary ICU of CMJAH over a 20-year period, from 1998 to 2017. Demographic data, clinical features, management and outcomes of patients were assessed and reviewed from the case records. Results Thirty-four patients with MG were admitted to the ICU during this period: 24 female and 10 male. The mean age ± SD was 37.4 ± 13.0 years, with a range of 16 - 66 years. Four patients were human immunodeficiency virus (HIV)-positive. The mean length of stay (LOS) in ICU was 10.6 ± 20.1 days, ranging from 1 to 115 days. Two patients were diagnosed with MG in the ICU after failure to wean from the ventilator. Overall, 22 patients were intubated and ventilated on admission. Morbidities included self-extubation, aspiration pneumonia and iatrogenic pneumothorax. History of thymectomy was present in 12 patients. The treatments received for MG included pyridostigmine (73.5%), corticosteroids (55.9%), azathioprine (35.3%), plasmapheresis (26.5%) and intravenous immunoglobulin (8.8%). The overall mortality in the ICU was 5.9%. Conclusion MG is a serious disorder with considerable morbidity and mortality. It is, however, a potentially manageable disease, provided that appropriate ICU resources are available. Contributions of the study This study provides further insight into the characteristics and outcomes of myasthenia gravis patients in ICU, within a South African context.
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Affiliation(s)
- R Morar
- School of Clinical Medicine, Faculty of Health Sciences; Division of Pulmonology and Critical Care, Department of Internal Medicine, Charlotte
Maxeke Johannesburg Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - GEMP 2 Group 6 of 2018 (M Amod, F Chappel, L Ebbeling, L Fikizolo, A Glover, K Gutu,
C Lawson, R Maswinyaneng, M Mohunlal, K Morar, D Rooken-Smith, K Seale, D Shai)
- GEMP 2 Group 6 of 2018, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - F Seedat
- School of Clinical Medicine, Faculty of Health Sciences; Division of Pulmonology and Critical Care, Department of Internal Medicine, Charlotte
Maxeke Johannesburg Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - G A Richards
- School of Clinical Medicine, Faculty of Health Sciences; Division of Pulmonology and Critical Care, Department of Internal Medicine, Charlotte
Maxeke Johannesburg Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
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19
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Ozyurt Kose S, Nazli E, Tutkavul K, Gilhus NE. Occurrence and severity of myasthenic crisis in an unselected Turkish cohort of patients with myasthenia gravis. Front Neurol 2023; 14:1201451. [PMID: 37521306 PMCID: PMC10374359 DOI: 10.3389/fneur.2023.1201451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 06/19/2023] [Indexed: 08/01/2023] Open
Abstract
Myasthenia gravis (MG) is a disorder of the neuromuscular junction that can deteriorate into myasthenic crisis, involving weakness of bulbar and respiratory muscles. In this study, we describe the clinical manifestations of myasthenic crisis, identify risk factors, and examine treatments and outcomes. All 95 patients with generalized MG treated at our center during the last 10 years were included in this retrospective study. We collected data from the patients' records, including clinical follow-ups, muscle antibodies, thymic status, and treatments. The characteristics of patients who did and did not experience myasthenic crisis were compared. Features of all myasthenic crises were also assessed. Twelve patients (13%) developed myasthenic crisis during the observation period. Men were more often affected at older ages. Seven patients experienced multiple myasthenic crises. Thymoma increased the risk of a crisis, whereas thymic hyperplasia decreased the risk. Myasthenic crises were more common in the summer months. No patients died during a myasthenic crisis. Risk factors for myasthenic crisis were thymoma, older age, MuSK antibodies, and previous crises. Individualized and active immunosuppressive treatment and optimal intensive care during crises provide a good outcome for patients with generalized MG.
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Affiliation(s)
- Selen Ozyurt Kose
- Department of Clinical Neurophysiology, Marmara University Pendik Teaching and Research Hospital, Istanbul, Turkey
| | - Ezgi Nazli
- Department of Neurology, Health Sciences University Haydarpasa Numune Teaching and Research Hospital, Istanbul, Turkey
| | - Kemal Tutkavul
- Department of Neurology, Health Sciences University Haydarpasa Numune Teaching and Research Hospital, Istanbul, Turkey
| | - Nils Erik Gilhus
- Department of Neurology, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
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20
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Hansen M, Neilson L, Parikh M, Katirji B. Greater Number of Plasma Exchanges Does Not Improve Outcome in Myasthenic Crisis. J Clin Neuromuscul Dis 2023; 24:199-206. [PMID: 37219863 DOI: 10.1097/cnd.0000000000000421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
OBJECTIVES To determine the relationship between the number of plasma exchanges and clinical outcome in patients experiencing myasthenic crisis. METHODS We retrospectively reviewed all episodes of myasthenia gravis exacerbation/crisis who received plasmapheresis in patients admitted to a single-center tertiary care referral center from July 2008 to July 2017. We performed statistical analyses to determine whether the increased number of plasma exchanges improves the primary outcome (hospital length of stay) and the secondary outcome (disposition to home, skilled nursing facility, long-term acute care hospital, or death). RESULTS There is neither clinically observable nor statistically significant improvement in length of stay or disposition on discharge in patients who received 6 or greater sessions of plasmapheresis. CONCLUSIONS This study provides class IV evidence that extending the number of plasma exchanges beyond 5 does not correlate with decreased hospital length of stay or improved discharge disposition in patients experiencing myasthenic crisis.
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Affiliation(s)
- Michael Hansen
- Department of Neurology, University Hospitals Cleveland Medical Center, Cleveland, OH. Dr. Hansen is now with the Department of Neurology, University of Wisconsin, Madison, WI. Dr. Neilson is now with the Department of Neurology, Oregon Health and Science University, Portland, OR, and the Department of Neurology, Veterans Affairs Medical Center, Portland, OR. Dr. Parikh is now with the Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA.; and
- Case Western Reserve University School of Medicine, Cleveland, OH
| | - Lee Neilson
- Department of Neurology, University Hospitals Cleveland Medical Center, Cleveland, OH. Dr. Hansen is now with the Department of Neurology, University of Wisconsin, Madison, WI. Dr. Neilson is now with the Department of Neurology, Oregon Health and Science University, Portland, OR, and the Department of Neurology, Veterans Affairs Medical Center, Portland, OR. Dr. Parikh is now with the Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA.; and
- Case Western Reserve University School of Medicine, Cleveland, OH
| | - Melanie Parikh
- Department of Neurology, University Hospitals Cleveland Medical Center, Cleveland, OH. Dr. Hansen is now with the Department of Neurology, University of Wisconsin, Madison, WI. Dr. Neilson is now with the Department of Neurology, Oregon Health and Science University, Portland, OR, and the Department of Neurology, Veterans Affairs Medical Center, Portland, OR. Dr. Parikh is now with the Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA.; and
- Case Western Reserve University School of Medicine, Cleveland, OH
| | - Bashar Katirji
- Department of Neurology, University Hospitals Cleveland Medical Center, Cleveland, OH. Dr. Hansen is now with the Department of Neurology, University of Wisconsin, Madison, WI. Dr. Neilson is now with the Department of Neurology, Oregon Health and Science University, Portland, OR, and the Department of Neurology, Veterans Affairs Medical Center, Portland, OR. Dr. Parikh is now with the Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA.; and
- Case Western Reserve University School of Medicine, Cleveland, OH
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21
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Valjarevic S, Lakicevic M, Jovanovic MB, Gavric J, Radaljac D. Emergency Tracheostomy Due to a Myasthenic Crisis in a Post-COVID Patient: Report of a Case. SN COMPREHENSIVE CLINICAL MEDICINE 2023; 5:148. [PMID: 37275565 PMCID: PMC10227813 DOI: 10.1007/s42399-023-01487-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/22/2023] [Indexed: 06/07/2023]
Abstract
Myasthenia gravis is an autoimmune disorder caused by the production of antibodies that block either acetylcholine receptors or structural receptors of the neuromuscular junction. There is expanding evidence that novel coronavirus (2019-nCoV) disease can lead to the development of an autoimmune response. Myasthenic crisis, a life-threatening respiratory muscle weakness severe enough to necessitate intubation or tracheostomy, can be a potential complication of myasthenia gravis. In this report, we describe the case of a 57-year-old man with acute respiratory insufficiency requiring emergency tracheostomy. His health condition rapidly deteriorated 1 week after initiating systemic corticosteroid treatment for a suspected adult-onset asthma exacerbation. The patient had a history of COVID-19 infection and thymectomy, which were noted in his medical records. Serological testing and electrodiagnostic evaluation confirmed the diagnosis of myasthenia gravis. The patient was treated with plasma exchange, continuous neostigmine infusion, and prednisone. He was successfully decannulated and discharged with anticholinesterase inhibitors and long-term immunosuppression therapy. It is important to consider neurological disorders in the differential diagnosis for patients presenting with respiratory insufficiency, particularly during the COVID-19 pandemic.
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Affiliation(s)
- Svetlana Valjarevic
- Department of Otorhinolaryngology with Maxillofacial Surgery, Clinical Hospital Center “Zemun”, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Dr Subotica Starijeg 8, 11000 Belgrade, Serbia
| | - Mirko Lakicevic
- Faculty of Medicine, University of Belgrade, Dr Subotica Starijeg 8, 11000 Belgrade, Serbia
- Department of Anesthesia, Resuscitation, and Pain Therapy, Clinical Hospital Center “Zemun”, Belgrade, Serbia
| | - Milan B. Jovanovic
- Department of Otorhinolaryngology with Maxillofacial Surgery, Clinical Hospital Center “Zemun”, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Dr Subotica Starijeg 8, 11000 Belgrade, Serbia
| | - Jelena Gavric
- Department of Otorhinolaryngology with Maxillofacial Surgery, Clinical Hospital Center “Zemun”, Belgrade, Serbia
| | - Dejan Radaljac
- Department of Otorhinolaryngology with Maxillofacial Surgery, Clinical Hospital Center “Zemun”, Belgrade, Serbia
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22
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Claytor B, Cho SM, Li Y. Myasthenic crisis. Muscle Nerve 2023. [PMID: 37114503 DOI: 10.1002/mus.27832] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Revised: 04/06/2023] [Accepted: 04/09/2023] [Indexed: 04/29/2023]
Abstract
Myasthenic crisis (MC) is a life-threatening manifestation of myasthenia gravis (MG) defined by respiratory insufficiency that requires the use of invasive or non-invasive ventilation. This is often the result of respiratory muscle weakness but can also be due to bulbar weakness with upper airway collapse. MC occurs in approximately 15%-20% of patients with MG usually within the first 2 to 3 y of the disease course. Many crises have a specific trigger with respiratory infections being most common; however, no specific trigger is found in 30%-40% of patients. MG patients with a history of MC, severe disease, oropharyngeal weakness, muscle-specific kinase (MuSK) antibodies and thymoma appear to be at higher risk. Most episodes of MC do not occur suddenly, providing a window of opportunity for prevention. Immediate treatment is directed toward airway management and removing any identified triggers. Plasmapheresis is preferred over intravenous immune globulin as the treatments of choice for MC. The majority of patients are able to be weaned from mechanical ventilation within 1 mo and the outcomes of MC are generally favorable. The mortality rate in United States cohorts is less than 5% and mortality in MC seems to be driven by age and other medical co-morbidities. MC does not appear to affect long-term prognosis as many patients are able to eventually achieve good MG control.
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Affiliation(s)
- Benjamin Claytor
- Neuromuscular Center, Department of Neurology, Neurological Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Sung-Min Cho
- Division of Neuroscience Critical Care, Departments of Neurology, Neurosurgery, Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Yuebing Li
- Neuromuscular Center, Department of Neurology, Neurological Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
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23
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Gilhus NE. Myasthenia gravis, respiratory function, and respiratory tract disease. J Neurol 2023:10.1007/s00415-023-11733-y. [PMID: 37101094 PMCID: PMC10132430 DOI: 10.1007/s00415-023-11733-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 04/14/2023] [Accepted: 04/16/2023] [Indexed: 04/28/2023]
Abstract
Myasthenia gravis (MG) is characterized by muscle weakness caused by autoantibodies that bind to the postsynaptic membrane at the neuromuscular junction and impair acetylcholine receptor function. Weakness of respiratory muscles represents the most severe MG manifestation, and 10-15% of all patients experience an MG crisis with the need of mechanical ventilatory support at least once in their life. MG patients with respiratory muscle weakness need active immunosuppressive drug treatment long term, and they need regular specialist follow-up. Comorbidities affecting respiratory function need attention and optimal treatment. Respiratory tract infections can lead to MG exacerbations and precipitate an MG crisis. Intravenous immunoglobulin and plasma exchange are the core treatments for severe MG exacerbations. High-dose corticosteroids, complement inhibitors, and FcRn blockers represent fast-acting treatments that are effective in most MG patients. Neonatal myasthenia is a transient condition with muscle weakness in the newborn caused by mother's muscle antibodies. In rare cases, treatment of respiratory muscle weakness in the baby is required.
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Affiliation(s)
- Nils Erik Gilhus
- Department of Neurology, Haukeland University Hospital, 5021, Bergen, Norway.
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.
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24
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Alcantara M, Koh M, Park AL, Bril V, Barnett C. Outcomes of COVID-19 Infection and Vaccination Among Individuals With Myasthenia Gravis. JAMA Netw Open 2023; 6:e239834. [PMID: 37097637 PMCID: PMC10130942 DOI: 10.1001/jamanetworkopen.2023.9834] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/26/2023] Open
Abstract
Importance There are limited data regarding COVID-19 outcomes and vaccine uptake and safety among people with myasthenia gravis (MG). Objective To investigate COVID-19-related outcomes and vaccine uptake among a population-based sample of adults with MG. Design, Setting, and Participants This population-based, matched cohort study in Ontario, Canada, used administrative health data from January 15, 2020, and August 31, 2021. Adults with MG were identified using a validated algorithm. Each patient was matched by age, sex, and geographic area of residence to 5 controls from the general population and from a cohort of individuals with rheumatoid arthritis (RA). Exposure Patients with MG and matched controls. Main Outcomes and Measures Main outcomes were COVID-19 infection and related hospitalizations, intensive care unit admissions, and 30-day mortality among patients with MG vs controls. Secondary outcomes were uptake of COVID-19 vaccination among patients with MG vs controls. Results Among 11 365 233 eligible Ontario residents, 4411 patients with MG (mean [SD] age, 67.7 [15.6] years; 2274 women [51.6%]) were matched to 22 055 general population controls (mean [SD] age, 67.7 [15.6] years; 11 370 women [51.6%]) and 22 055 controls with RA (mean [SD] age, 67.7 [15.6] years; 11 370 women [51.6%]). In the matched cohort, 38 861 of 44 110 individuals (88.1%) were urban residents; in the MG cohort, 3901 (88.4%) were urban residents. Between January 15, 2020, and May 17, 2021, 164 patients with MG (3.7%), 669 general population controls (3.0%), and 668 controls with RA (3.0%) contracted COVID-19. Compared with general population controls and controls with RA, patients with MG had higher rates of COVID-19-associated emergency department visits (36.6% [60 of 164] vs 24.4% [163 of 669] vs 29.9% [200 of 668]), hospital admissions (30.5% [50 of 164] vs 15.1% [101 of 669] vs 20.7% [138 of 668]), and 30-day mortality (14.6% [24 of 164] vs 8.5% [57 of 669] vs 9.9% [66 of 668]). By August 2021, 3540 patients with MG (80.3%) vs 17 913 general population controls (81.2%) had received 2 COVID-19 vaccine doses, and 137 (3.1%) vs 628 (2.8%), respectively had received 1 dose. Of 3461 first vaccine doses for patients with MG, fewer than 6 individuals were hospitalized for MG worsening within 30 days of vaccination. Vaccinated patients with MG had a lower risk than unvaccinated patients with MG of contracting COVID-19 (hazard ratio, 0.43; 95% CI, 0.30-0.60). Conclusions and Relevance This study suggests that adults with MG who contracted COVID-19 had a higher risk of hospitalization and death compared with matched controls. Vaccine uptake was high, with negligible risk of severe MG exacerbations after vaccination, as well as evidence of effectiveness. The findings support public health policies prioritizing people with MG for vaccination and new COVID-19 therapeutics.
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Affiliation(s)
- Monica Alcantara
- Ellen & Martin Prosserman Centre for Neuromuscular Diseases, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | | | | | - Vera Bril
- Ellen & Martin Prosserman Centre for Neuromuscular Diseases, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Carolina Barnett
- Ellen & Martin Prosserman Centre for Neuromuscular Diseases, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
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25
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Schirò G, Iacono S, Balistreri CR. The Role of Human Microbiota in Myasthenia Gravis: A Narrative Review. Neurol Int 2023; 15:392-404. [PMID: 36976669 PMCID: PMC10053295 DOI: 10.3390/neurolint15010026] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 03/05/2023] [Accepted: 03/07/2023] [Indexed: 03/15/2023] Open
Abstract
Myasthenia gravis (MG) is an autoimmune neuromuscular disease characterized by fluctuating weakness of the skeletal muscles. Although antibodies against the neuromuscular junction components are recognized, the MG pathogenesis remains unclear, even if with a well-known multifactorial character. However, the perturbations of human microbiota have been recently suggested to contribute to MG pathogenesis and clinical course. Accordingly, some products derived from commensal flora have been demonstrated to have anti-inflammatory effects, while other have been shown to possess pro-inflammatory properties. In addition, patients with MG when compared with age-matched controls showed a distinctive composition in the oral and gut microbiota, with a typical increase in Streptococcus and Bacteroides and a reduction in Clostridia as well as short-chain fatty acid reduction. Moreover, restoring the gut microbiota perturbation has been evidenced after the administration of probiotics followed by an improvement of symptoms in MG cases. To highlight the role of the oral and gut microbiota in MG pathogenesis and clinical course, here, the current evidence has been summarized and reviewed.
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Affiliation(s)
- Giuseppe Schirò
- Neurology Unit, Department of Biomedicine, Neuroscience and Advanced Diagnostics (BiND), University of Palermo, 90127 Palermo, Italy
| | - Salvatore Iacono
- Neurology Unit, Department of Biomedicine, Neuroscience and Advanced Diagnostics (BiND), University of Palermo, 90127 Palermo, Italy
- Correspondence:
| | - Carmela Rita Balistreri
- Cellular and Molecular Laboratory, Department of Biomedicine, Neuroscience and Advanced Diagnostics (BiND), University of Palermo, 90127 Palermo, Italy
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26
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Zhong H, Ruan Z, Yan C, Lv Z, Zheng X, Goh LY, Xi J, Song J, Luo L, Chu L, Tan S, Zhang C, Bu B, Da Y, Duan R, Yang H, Luo S, Chang T, Zhao C. Short-term outcome prediction for myasthenia gravis: an explainable machine learning model. Ther Adv Neurol Disord 2023; 16:17562864231154976. [PMID: 36860354 PMCID: PMC9969443 DOI: 10.1177/17562864231154976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 01/15/2023] [Indexed: 02/26/2023] Open
Abstract
Background Myasthenia gravis (MG) is an autoimmune disease characterized by muscle weakness and fatigability. The fluctuating nature of the disease course impedes the clinical management. Objective The purpose of the study was to establish and validate a machine learning (ML)-based model for predicting the short-term clinical outcome in MG patients with different antibody types. Methods We studied 890 MG patients who had regular follow-ups at 11 tertiary centers in China from 1 January 2015 to 31 July 2021 (653 patients for derivation and 237 for validation). The short-term outcome was the modified post-intervention status (PIS) at a 6-month visit. A two-step variable screening was used to determine the factors for model construction and 14 ML algorithms were used for model optimisation. Results The derivation cohort included 653 patients from Huashan hospital [age 44.24 (17.22) years, female 57.6%, generalized MG 73.5%], and the validation cohort included 237 patients from 10 independent centers [age 44.24 (17.22) years, female 55.0%, generalized MG 81.2%]. The ML model identified patients who were improved with an area under the receiver operating characteristic curve (AUC) of 0.91 [0.89-0.93], 'Unchanged' 0.89 [0.87-0.91], and 'Worse' 0.89 [0.85-0.92] in the derivation cohort, whereas identified patients who were improved with an AUC of 0.84 [0.79-0.89], 'Unchanged' 0.74 [0.67-0.82], and 'Worse' 0.79 [0.70-0.88] in the validation cohort. Both datasets presented a good calibration ability by fitting the expectation slopes. The model is finally explained by 25 simple predictors and transferred to a feasible web tool for an initial assessment. Conclusion The explainable, ML-based predictive model can aid in forecasting the short-term outcome for MG with good accuracy in clinical practice.
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Affiliation(s)
| | | | | | - Zhiguo Lv
- Department of Neurology, The Affiliated
Hospital of Changchun University of Chinese Medicine, Changchun, China
| | - Xueying Zheng
- Department of Biostatistics, School of Public
Health and Key Laboratory of Public Health Safety, Fudan University,
Shanghai, China
| | - Li-Ying Goh
- Shanghai Medical College, Fudan University,
Shanghai, China
| | - Jianying Xi
- Huashan Rare Disease Center, Department of
Neurology, Huashan Hospital, Fudan University, Shanghai, China,National Center for Neurological Disorders,
Shanghai, China
| | - Jie Song
- Huashan Rare Disease Center, Department of
Neurology, Huashan Hospital, Fudan University, Shanghai, China,National Center for Neurological Disorders,
Shanghai, China
| | - Lijun Luo
- Department of Neurology, Wuhan No.1 Hospital,
Wuhan, China
| | - Lan Chu
- Department of Neurology, The Affiliated
Hospital of Guizhou Medical University, Guiyang, China
| | - Song Tan
- Department of Neurology, Sichuan Provincial
People’s Hospital, University of Electronic Science and Technology of China,
Chengdu, China
| | - Chao Zhang
- Department of Neurology and Tianjin
Neurological Institute, Tianjin Medical University General Hospital,
Tianjin, China
| | - Bitao Bu
- Department of Neurology, Tongji Hospital,
Tongji Medical College, Huazhong University of Science and Technology,
Wuhan, China
| | - Yuwei Da
- Department of Neurology, Xuanwu Hospital,
Capital Medical University, Beijing, China
| | - Ruisheng Duan
- Department of Neurology, The First Affiliated
Hospital of Shandong First Medical University, Jinan, China
| | - Huan Yang
- Department of Neurology, Xiangya Hospital,
Central South University, Changsha, China
| | | | - Ting Chang
- Department of Neurology, Tangdu Hospital, The
Air Force Medical University, Xi’an 710000, China
| | - Chongbo Zhao
- Huashan Rare Disease Center, Department of
Neurology, Huashan Hospital, Fudan University, Shanghai 200040, China,National Center for Neurological Disorders,
Shanghai, China
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Durán Barata D, Fedirchyk O, Corral Tuesta C. Levofloxacin as a possible cause of myasthenic crisis. Med Clin (Barc) 2023; 160:464-466. [PMID: 36822981 DOI: 10.1016/j.medcli.2023.01.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Revised: 01/04/2023] [Accepted: 01/05/2023] [Indexed: 02/23/2023]
Affiliation(s)
- Diego Durán Barata
- Servicio de Neumología, Hospital Universitario Ramón y Cajal, Universidad de Alcalá de Henares, Madrid, España.
| | - Olga Fedirchyk
- Servicio de Neurofisiología, Hospital Universitario Ramón y Cajal, Madrid, España
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The diagnostic and prognostic utility of repetitive nerve stimulation in patients with myasthenia gravis. Sci Rep 2023; 13:2985. [PMID: 36806815 PMCID: PMC9941475 DOI: 10.1038/s41598-023-30154-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Accepted: 02/16/2023] [Indexed: 02/22/2023] Open
Abstract
Repetitive nerve stimulation (RNS) is a standard test for the diagnosis of myasthenia gravis (MG), where decrement of compound muscle action potentials (CMAP) corresponds to clinical muscle fatigability. Our aim was to ascertain the diagnostic and prognostic utility of RNS in MG patients. This study included MG patients treated between 01/2000 and 12/2016, with an observational period of at least one year and a minimum of two neurological examinations. Clinical and electrophysiological data were retrospectively gathered from patient records, and CMAP decrement was correlated with autoantibody titers and clinical disease severity at different time points. Ninety-four patients were included, with 88.3% of the cohort testing positive for acetylcholine receptor autoantibodies (AChR-Abs). RNS sensitivity was higher in patients with generalized disease (71.6%) than in purely ocular MG (38.5%). CMAP decrement did not significantly correlate with AChR-Ab titers, nor with clinical symptom severity at the time of testing or last follow up. However, there was a significant correlation between CMAP decrement and the worst recorded clinical status on a group level. RNS testing is more sensitive in generalized disease and AChR-Ab positive patients, but our data do not support RNS as a tool for long-term outcome prediction. Future studies with a prospective study design could help to overcome a number of limiting factors discussed in our study.
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Saldanha Marques J, Santos P. Unexpected Myasthenic Crisis in Anesthesia for Magnetic Resonance Imaging - Diagnosis and Management. Cureus 2023; 15:e34959. [PMID: 36938277 PMCID: PMC10018574 DOI: 10.7759/cureus.34959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/14/2023] [Indexed: 02/16/2023] Open
Abstract
Myasthenic crisis (MC) is a rare and life-threatening manifestation of myasthenia gravis (MG) and is characterized by rapidly progressing weakness of respiratory and bulbar muscles leading to immobility, severe dyspnea, respiratory insufficiency, and possible aspiration. Early recognition and prompt treatment may prevent the development of further complications and the need for intubation, invasive mechanical ventilation, and ICU admission. Its diagnosis requires a high degree of clinical suspicion, and anesthesiologists, despite being prepared to deal with and provide anesthesia care to patients with MG, may not be immediately aware of the correct diagnosis and treatment of this medical emergency, and of the red flags that should prompt more invasive measures. Due to the very low incidence and possibly high morbidity of the condition, it is important to report cases of perioperative MC to raise awareness for early diagnosis and treatment. This case also emphasizes the importance of pre-anesthetic consultation and a multidisciplinary approach with appropriate communication and referral between medical specialties as the diagnosis of MG was not disclosed to the anesthetic team. The organizational, communication and safety gaps that occurred during the perioperative period could potentially have had a negative impact on patient outcomes. We report a case of MC in a patient who underwent general anesthesia for ambulatory magnetic resonance imaging and whose diagnosis of MG was not conveyed to the anesthesia care team.
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Affiliation(s)
| | - Patrícia Santos
- Anesthesiology, Centro Hospitalar Universitário de São João, Porto, PRT
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30
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Frequency and Correlates of Mild Cognitive Impairment in Myasthenia Gravis. Brain Sci 2023; 13:brainsci13020170. [PMID: 36831713 PMCID: PMC9953757 DOI: 10.3390/brainsci13020170] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 01/14/2023] [Accepted: 01/17/2023] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Antibodies against acetylcholine receptors (AChRs) can also target nicotinic AChRs that are present throughout the central nervous system, thus leading to cognitive dysfunctions in patients with myasthenia gravis (MG). However, the presence of cognitive impairment in MG is controversial, and the factors that may influence this risk are almost completely unknown. In this study, the frequency of mild cognitive impairment (MCI) in MG, as well as the clinical, immunological, and behavioral correlates of MCI in MG were evaluated. METHODS A total of 52 patients with MG underwent a comprehensive assessment including motor and functional scales, serological testing, and neuropsychological and behavioral evaluation. RESULTS The frequency of MCI was 53.8%, and the most impaired cognitive domains were, in order, visuoconstructive/visuospatial skills, memory, and attention. After multivariate analysis, only pyridostigmine use was inversely associated with the presence of MCI, while a trend toward a positive association between MCI and disease severity and arms/legs hyposthenia was found. Correlation analyses showed that daily doses of prednisone and azathioprine significantly correlated with depressive symptomatology, while disease severity significantly correlated with depressive symptomatology and sleep disturbance. CONCLUSIONS The presence of MCI is rather frequent in MG and is characterized by multidomain amnestic impairment. Such preliminary data need further confirmation on larger case series.
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31
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Stascheit F, Grittner U, Hoffmann S, Mergenthaler P, Schroeter M, Ruck T, Pawlitzki M, Blaes F, Kaiser J, Schara U, Della-Marina A, Thieme A, Hagenacker T, Jacobi C, Berger B, Urban PP, Knop KC, Schalke B, Lee DH, Kalischewski P, Wiendl H, Meisel A. Risk and course of COVID-19 in immunosuppressed patients with myasthenia gravis. J Neurol 2023; 270:1-12. [PMID: 36166068 PMCID: PMC9512984 DOI: 10.1007/s00415-022-11389-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 09/16/2022] [Accepted: 09/17/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND Patients with myasthenia gravis (MG) are potentially prone for a severe COVID-19 course, but there are limited real-world data available on the risk associated with COVID-19 for patients with MG. Here, we investigate whether current immunosuppressive therapy (IST) influences the risk of SARS-CoV-2 infection and COVID-19 severity. METHODS Data from the German myasthenia gravis registry were analyzed from May 2020 until June 2021 and included patient demographics, MG disease duration, comorbidities, current IST use, COVID-19 characteristics, and outcomes. Propensity score matching was employed to match MG patients with IST to those without, and multivariable binary logistic regression models were used to determine associations between IST with (1) symptomatic SARS-CoV-2 infection and (2) severe COVID-19 course, as measured by hospitalization or death. RESULTS Of 1379 patients with MG, 95 (7%) patients (mean age 58 (standard deviation [SD] 18) presented with COVID-19, of which 76 (80%) received IST at time of infection. 32 patients (34%) were hospitalized due to COVID-19; a total of 11 patients (12%) died. IST was a risk factor for hospitalization or death in the group of COVID-19-affected MG patients (odds ratio [OR] 3.04, 95% confidence interval [CI] = 1.02-9.06, p = 0.046), but current IST was not associated with a higher risk for SARS-CoV-2 infection itself. DISCUSSION In this national MG cohort study, current IST use was a risk factor for a severe disease course of COVID-19 but not for SARS-CoV-2 infection itself. These data support the consequent implementation of effective strategies to prevent COVID-19 in this high-risk group. TRIAL REGISTRATION INFORMATION German clinical trial registry ( https://www.drks.de ), DRKS00024099, first patient enrolled: February 4th, 2019.
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Affiliation(s)
- Frauke Stascheit
- Department of Neurology with Experimental Neurology, Charité — Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany ,NeuroCure Clinical Research Center, Charité — Universitätsmedizin Berlin, Berlin, Germany
| | - Ulrike Grittner
- Institute of Biometry and Clinical Epidemiology, Charité-Universitätsmedizin Berlin, Berlin, Germany ,Berlin Institute of Health at Charité – Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Sarah Hoffmann
- Department of Neurology with Experimental Neurology, Charité — Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany ,NeuroCure Clinical Research Center, Charité — Universitätsmedizin Berlin, Berlin, Germany
| | - Philipp Mergenthaler
- Department of Neurology with Experimental Neurology, Charité — Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany ,NeuroCure Clinical Research Center, Charité — Universitätsmedizin Berlin, Berlin, Germany ,Center for Stroke Research Berlin, Charité — Universitätsmedizin Berlin, Berlin, Germany
| | - Michael Schroeter
- Department of Neurology, University of Cologne and University Hospital, Cologne, Germany
| | - Tobias Ruck
- Department of Neurology, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Mark Pawlitzki
- Department of Neurology, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Franz Blaes
- Department of Neurology, Kreiskrankenhaus Oberberg GmbH, Oberberg, Germany
| | - Julia Kaiser
- Department of Neurology, LVR Klinik Bonn, Bonn, Germany
| | - Ulrike Schara
- Department of Neuropediatric, University of Duisburg-Essen, Essen, Germany
| | - Adela Della-Marina
- Department of Neuropediatric, University of Duisburg-Essen, Essen, Germany
| | - Andrea Thieme
- Department of Neurology, Helios Hospital Erfurt, Erfurt, Germany
| | - Tim Hagenacker
- Department of Neurology Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Medicine Essen, Essen, Germany
| | - Christian Jacobi
- Department of Neurology, Sankt Katharinen Krankenhaus GmbH, Frankfurt, Germany
| | - Benjamin Berger
- Department of Neurology, Helios Hospital Pforzheim, Pforzheim, Germany ,Clinic of Neurology and Neurophysiology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Peter P. Urban
- Department of Neurology, Asklepios Hospital Hamburg Barmbek, Hamburg, Germany
| | | | - Berthold Schalke
- Department of Neurology, University of Regensburg, Regensburg, Germany
| | - De-Hyung Lee
- Department of Neurology, University of Regensburg, Regensburg, Germany
| | | | - Heinz Wiendl
- Department of Neurology, University of Münster, Münster, Germany
| | - Andreas Meisel
- Department of Neurology with Experimental Neurology, Charité — Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany ,NeuroCure Clinical Research Center, Charité — Universitätsmedizin Berlin, Berlin, Germany ,Center for Stroke Research Berlin, Charité — Universitätsmedizin Berlin, Berlin, Germany
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32
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Su Y, Teng J, Tian F, Jing J, Huang H, Pan S, Jiang W, Wang F, Zhang L, Zhang Y, Zhang M, Liu L, Cao J, Hu H, Li W, Liang C, Ma L, Meng X, Tian L, Wang C, Wang L, Wang Y, Wang Z, Wang Z, Xie Z, You M, Yuan J, Zeng C, Zeng L, Zhang L, Zhang X, Zhang Y, Zhao B, Zhou S, Zhou Z. The development of neurocritical care in China from the perspective of evaluation and treatment of critical neurological diseases. Front Neurol 2023; 14:1114204. [PMID: 36895910 PMCID: PMC9990414 DOI: 10.3389/fneur.2023.1114204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 01/12/2023] [Indexed: 02/23/2023] Open
Abstract
Objective To understand the varieties, evaluation, treatment, and prognosis of severe neurological diseases using the third NCU survey in China. Design A cross-sectional questionnaire study. The study was completed in three main steps: filling in the questionnaire, sorting out the survey data, and analyzing the survey data. Results Of 206 NCUs, 165 (80%) provided relatively complete information. It was estimated that 96,201 patients with severe neurological diseases were diagnosed and treated throughout the year, with an average fatality rate of 4.1%. The most prevalent severe neurological disease was cerebrovascular disease (55.2%). The most prevalent comorbidity was hypertension (56.7%). The most prevalent complication was hypoproteinemia (24.2%). The most common nosocomial infection was hospital-acquired pneumonia (10.6%). The GCS, APACHE II, EEG, and TCD were the most commonly used (62.4-95.2%). The implementation rate of the five nursing evaluation techniques reached 55.8-90.9%. Routinely raising the head of the bed by 30°, endotracheal intubation and central venous catheterization were the mostprevalent treatment strategies (97.6, 94.5, and 90.3%, respectively). Traditional tracheotomy, invasive mechanical ventilation and nasogastric tube feeding (75.8, 95.8, and 95.8%, respectively) were more common than percutaneous tracheotomy, non-invasive mechanical ventilation and nasogastric tube insertion (57.6, 57.6, and 66.7%, respectively). Body surface hypothermia brain protection technology was more commonly used than intravascular hypothermia technology (67.3 > 6.1%). The rates of minimally invasive hematoma removal and ventricular puncture were only 40.0 and 45.5%, respectively. Conclusion In addition to traditional recognized basic life assessment and support technology, it is necessary to the use of promote specialized technology for neurological diseases, according to the characteristics of critical neurological diseases.
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Affiliation(s)
- Yingying Su
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Junfang Teng
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Fei Tian
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Jing Jing
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Huijin Huang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Suyue Pan
- Department of Neurology, Nanfang Hospital of Southern Medical University, Guangzhou, China
| | - Wen Jiang
- Department of Neurology, Xijing Hospital Fourth Military Medical University, Xi'an, China
| | - Furong Wang
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Le Zhang
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Yan Zhang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Meng Zhang
- Department of Neurology, Daping Hospital, The Army Military Medical University, Chongqing, China
| | - Liping Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jie Cao
- Department of Neurology, The First Hospital of Jilin University, Changchun, China
| | - Huaiqiang Hu
- Department of Neurology, The 960(th) Hospital of Joint Logistics Support, PLA, Jinan, China
| | - Wei Li
- Department of Neurology, Daping Hospital, The Army Military Medical University, Chongqing, China
| | - Cheng Liang
- Department of Neurology, The Second Hospital of Lanzhou University, Lanzhou, China
| | - Liansheng Ma
- Department of Neurology, The First Hospital of Shanxi Medical University, Taiyuan, China
| | - Xuegang Meng
- Department of Neurology, The Xinjiang Uygur Autonomous Region People's Hospital, Urumqi, China
| | - Linyu Tian
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Changqing Wang
- Department of Neurology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Lihua Wang
- Department of Neurology, The Second Affiliated Hospital, Harbin Medical University, Harbin, China
| | - Yan Wang
- Department of Neurology, Tangshan People's Hospital of Hebei Province, Tangshan, China
| | - Zhenhai Wang
- Neurology Center, General Hospital of Ningxia Medical University, Yinchuan, China
| | - Zhiqiang Wang
- Department of Neurology, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Zunchun Xie
- Department of Neurology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Mingyao You
- Department of Neurology, The Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Jun Yuan
- Department of Neurology, Inner Mongolia People's Hospital, Hohhot, China
| | - Chaosheng Zeng
- Department of Neurology, The Second Affiliated Hospital of Hainan Medical University, Haikou, China
| | - Li Zeng
- Department of Neurology, The Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Lei Zhang
- Department of Neurology, The First People's Hospital of Yunnan Province, Kunming, China
| | - Xin Zhang
- Department of Neurology, Nanjing Drum Tower Hospital, Nanjing, China
| | - Yongwei Zhang
- Department of Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Bin Zhao
- Department of Neurology, Tianjin Medical University General Hospital, Tianjin, China
| | - Saijun Zhou
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Zhonghe Zhou
- Department of Neurology, General Hospital of Northern Theater Command, Shenyang, China
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Myocardial Injury in Hospitalized Patients with Myasthenia Gravis. J Clin Med 2022; 11:jcm11237106. [PMID: 36498680 PMCID: PMC9741152 DOI: 10.3390/jcm11237106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Revised: 11/18/2022] [Accepted: 11/22/2022] [Indexed: 12/03/2022] Open
Abstract
Objective: To investigate the clinical characteristics and outcome of myocardial injury in patients with myasthenia gravis (MG). Methods: We retrospectively searched medical records to screen hospitalized patients with MG at our hospital. The troponin T (TnT) levels were deemed necessary to be performed based on the patient’s clinical symptoms and were used as biomarkers of myocardial injury. The patients’ demographic and clinical information were collected. Death was the primary outcome. Results: A total of 336 patients with MG measured TnT levels and were included in the final analysis. The male MG patients with elevated TnT levels had a higher prevalence of infection (56.8% vs. 30.0%, p = 0.001) and myasthenic crisis (37.5% vs. 13.3%, p = 0.001) than those with normal TnT levels. Meanwhile, the female MG patients with elevated TnT levels were older (56.0 (16.6) vs. 49.2 (17.2)) years old, p = 0.007] and had a higher prevalence of infection (65.4% vs. 32.1%, p < 0.001), myasthenic crisis (33.6% vs. 17.9%, p = 0.015), and thymoma (38.5% vs. 16.7%, p = 0.001) than those with normal TnT levels. Older age (coef. = 0.004; p = 0.034), infection (coef. = 0.240; p = 0.001), myasthenic crisis (coef. = 0.312; p < 0.001), thymoma (coef. = 0.228; p = 0.001), and ICI therapy (coef. = 1.220; p < 0.001) were independent risk predictors for increasing log TnT levels. Thirty-seven patients died during hospitalization. High log TnT levels (OR = 8.818; p < 0.001), female sex (OR = 0.346; p = 0.023), thymoma (OR = 5.092; p = 0.002), and infection (OR = 14.597; p < 0.001) were independent risk predictors of death. Conclusions: Our study revealed that the surveillance of myocardial injury biomarkers in MG patients might be beneficial.
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Zdraljevic M, Peric S, Jeremic M, Lavrnic D, Basta I, Hajdukovic L, Jovanovic DR, Berisavac I. Myasthenia gravis treated in the neurology intensive care unit: a 14-year single-centre experience. Neurol Sci 2022; 43:6909-6918. [DOI: 10.1007/s10072-022-06379-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 09/01/2022] [Indexed: 11/24/2022]
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35
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Ruan H, Lin S, Liu F, Zhao C, Gong C, Li Y, Wang J, Yang X. Key Factors Associated With Administration of Ventilator Support After Thymoma Resection. J Surg Res 2022; 277:67-75. [DOI: 10.1016/j.jss.2022.03.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 02/18/2022] [Accepted: 03/19/2022] [Indexed: 11/30/2022]
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36
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A case of autoimmune hepatitis with thymoma and myasthenia gravis. Clin J Gastroenterol 2022; 15:765-770. [DOI: 10.1007/s12328-022-01641-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 05/01/2022] [Indexed: 10/17/2022]
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37
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Tonev D, Georgieva R, Vavrek E. Our Clinical Experience in the Treatment of Myasthenia Gravis Acute Exacerbations with a Novel Nanomembrane-Based Therapeutic Plasma Exchange Technology. J Clin Med 2022; 11:jcm11144021. [PMID: 35887784 PMCID: PMC9322121 DOI: 10.3390/jcm11144021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 07/07/2022] [Accepted: 07/08/2022] [Indexed: 11/16/2022] Open
Abstract
According to the American Academy of Neurology 2011 guidelines, there is insufficient evidence to support or refute the use of therapeutic plasma exchange (TPE) for myasthenia gravis (MG). The goal of this study was to determine whether a novel nanomembrane-based TPE could be useful in the treatment of MG. Thirty-six adult patients, MGFA 4/4B and 5, with acute MG episodes were enrolled into a single-center retrospective before-and-after study to compare a conventional treatment group (n = 24) with a nanomembrane-based TPE group (n = 12). TPE or intravenous immunoglobulins (IVIG) infusions were used in impending/manifested myasthenic crises, especially in patients at high-risk for prolonged invasive ventilation (IMV) and in those tolerating non-invasive ventilation (NIV). The clinical improvement was assessed using the Myasthenia Muscle Score (0–100), with ≥20 increase for responders. The primary outcome measures included the rates of implemented TPE, IVIG, and corticosteroids immunotherapies, NIV/IMV, early tracheotomy, MMS scores, extubation time, neuro-ICU/hospital LOS, complications, and mortality rates. The univariate analysis found that IMV was lower in the nanomembrane-based group (42%) compared to the conventional treatment group (83%) (p = 0.02). The multivariate analysis using binary logistic regression revealed TPE and NIV as independent predictors for short-term (≤7 days) respiratory support (p = 0.014 for TPE; p = 0.002 for NIV). The novel TPE technology moved our clinical practice towards proactive rather than protective treatment in reducing prolonged IMV during MG acute exacerbations.
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Affiliation(s)
- Dimitar Tonev
- Department of Anesthesiology and Intensive Care, Medical University of Sofia, Academician Ivan Geshov Blvd 15, 1431 Sofia, Bulgaria; (R.G.); (E.V.)
- Department of Anesthesiology and Intensive Care, University Hospital “Tsaritsa Yoanna-ISUL”, Belo More Str. 8, 1527 Sofia, Bulgaria
- Correspondence:
| | - Radostina Georgieva
- Department of Anesthesiology and Intensive Care, Medical University of Sofia, Academician Ivan Geshov Blvd 15, 1431 Sofia, Bulgaria; (R.G.); (E.V.)
- Neurological Intensive Care Unit, Department of Neurology, University Hospital “Tsaritsa Yoanna-ISUL”, Belo More Str. 8, 1527 Sofia, Bulgaria
| | - Evgeniy Vavrek
- Department of Anesthesiology and Intensive Care, Medical University of Sofia, Academician Ivan Geshov Blvd 15, 1431 Sofia, Bulgaria; (R.G.); (E.V.)
- Neurological Intensive Care Unit, Department of Neurology, University Hospital “Tsaritsa Yoanna-ISUL”, Belo More Str. 8, 1527 Sofia, Bulgaria
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38
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Peng X, Xie XB, Tan H, Zhang D, Jiang BT, Liu J, Li S, Chen YR, Xie TY. Effects of Plasma Exchange Combined with Immunoglobulin Therapy on Consciousness, Immune Function, and Prognosis in Patients with Myasthenia Gravis Crisis: A Prospective Randomized Test. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2022; 2022:7796833. [PMID: 35813442 PMCID: PMC9262518 DOI: 10.1155/2022/7796833] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 05/30/2022] [Accepted: 06/09/2022] [Indexed: 12/02/2022]
Abstract
Background Myasthenia gravis (MG) is an acquired autoimmune disease. The main clinical features of MG are skeletal muscle fatigue and pathological fatigue, which worsen at night or after fatigue, such as dyspnea, dysphagia, and systemic weakness. Plasma exchange (PE) is often used in patients with acute exacerbation of MG. Intravenous immunoglobulin (IVIG) is a collection of immunoglobulins from thousands of donors. IVIG can replace a variety of immunosuppressants or PE. However, the effect of PE or IVIG on patients' consciousness, immune function, and prognosis is not clear. Objective A prospective randomized test of the effects of PE combined with immunoglobulin on consciousness, immune function, and prognosis in patients with myasthenia gravis crisis (MGC). Methods Sixty patients with MGC treated from February 2019 to April 2021 were enrolled in our hospital. The cases who received PE were set as the PE group, and those who received PE combined with immunoglobulin were set as the PE+immunoglobulin group. The efficacy, clinical score, state of consciousness, immune function, acetylcholine receptor antibody (AChR-Ab), lymphocyte (LYM), albumin (ALB) levels, and the incidence of adverse reactions were compared. Results The improvement rate was 100.005% in the treatment group and 83.33% in the PE group. After treatment, the clinical score of the PE+immunoglobulin group was lower than that of the PE group, and the clinical relative score of the PE+immunoglobulin group was higher than that of the PE group (P < 0.05). The number of conscious people in the PE+immunoglobulin group was more than that in the PE group (P < 0.05). Immunoglobulin A, immunoglobulin M, immunoglobulin G, and immunoglobulin G in the PE+immunoglobulin group were higher than those in the PE group (P < 0.05). The levels of AChR-Ab and ALB in the PE+immunoglobulin group were higher than those in the PE group, while the level of LYM in the PE+immunoglobulin group was lower than that in the PE group. The incidence of skin system, gastrointestinal system, nervous system, and systemic damage in the PE+immunoglobulin group was lower than that in the PE group (P < 0.05). Conclusion The treatment of MGC with PE combined with immunoglobulin can not only effectively enhance the consciousness and immune function of patients but also effectively promote the prognosis, and the safety of treatment can be guaranteed.
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Affiliation(s)
- Xu Peng
- Department of Neurology, The First Hospital of Changsha, Changsha, Hunan 410005, China
| | - Xiao-Bi Xie
- Department of Cardiology, The First Hospital of Changsha, Changsha, Hunan 410005, China
| | - Hong Tan
- Department of Neurology, The First Hospital of Changsha, Changsha, Hunan 410005, China
| | - Dan Zhang
- Department of Neurology, The First Hospital of Changsha, Changsha, Hunan 410005, China
| | - Bo-Tao Jiang
- Department of Neurology, The First Hospital of Changsha, Changsha, Hunan 410005, China
| | - Jie Liu
- Department of Neurology, The First Hospital of Changsha, Changsha, Hunan 410005, China
| | - Shuang Li
- Department of Neurology, The First Hospital of Changsha, Changsha, Hunan 410005, China
| | - Ya-Rui Chen
- Department of Neurology, The First Hospital of Changsha, Changsha, Hunan 410005, China
| | - Tao-Yang Xie
- Department of Neurology, The First Hospital of Changsha, Changsha, Hunan 410005, China
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Intiso D, Centra AM, Amoruso L, Gravina M, Rienzo FD. Case Report: Functional Outcome of COVID-19 Subjects With Myasthenia Gravis and Critical Illness Polyneuropathy. Front Neurol 2022; 13:906402. [PMID: 35800084 PMCID: PMC9253533 DOI: 10.3389/fneur.2022.906402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 05/23/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundThe COVID-19 disease can affect subjects suffering from myasthenia gravis (MG) and worsen its clinical course, leading to intensive care unit (ICU) admission. Critically ill subjects can develop a neuromuscular complication called ICU-acquired weakness (ICUAW). This disorder has also been detected in ICU subjects with COVID-19, but the association between MG and ICUAW has never been described in critically ill patients. We describe the case and functional outcome of a COVID-19 patient suffering from MG who developed critical illness polyneuropathy (CIP).Case PresentationA 66-year-old man with a history of hypertension and ocular MG had COVID-19 and required ICU admission. The patient underwent mechanical ventilation and tracheotomy and was treated with remdesivir and corticosteroids. Fifteen days after admission, he complained of tetraparesis without the ocular involvement that remained unchanged despite the increase in anticholinesterase therapy. The length of stay (LOS) in ICU was 35 days. On day 2 of admission, the patient underwent a frontal muscle jitter study that confirmed the MG, and electroneurography (ENG) and electromyography (EMG) that showed overlapping ICUAW with electrophysiological signs characteristic of CIP. The cerebrospinal fluid (CSF) showed normal pressure, cell count, and protein levels (<45 mg/dl) without albumin-cytologic disassociation. The CSF/serum glucose ratio was normal. The CSF culture for possible organisms, laboratory tests for autoimmune disorders, the panel of antiganglioside antibodies, and the paraneoplastic syndrome were negative. Strength and functional outcomes were tested with the MRC scale, the DRS, Barthel scale, and the Functional Independence Measure (FIM) at admission, discharge, and follow-up. Muscular strength improved progressively, and the MRC scale sum-score was 50 at discharge. Anticholinesterase therapy with pyridostigmine at a dosage of 30 mg 3 times daily, which the patient was taking before COVID-19, was resumed. His motor abilities recovered, and functional evaluations showed full recovery at follow-up.ConclusionIn the described subject, the coexistence of both neuromuscular disorders did not affect the clinical course and recovery, but the question remains about generalization to all patients with MG. The rehabilitation interventions might have facilitated the outcome.
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Affiliation(s)
- Domenico Intiso
- Unit of Neuro-Rehabilitation, IRCCS “Casa Sollievo della Sofferenza”, San Giovanni Rotondo, Italy
- *Correspondence: Domenico Intiso ;
| | - Antonello Marco Centra
- Unit of Neuro-Rehabilitation, IRCCS “Casa Sollievo della Sofferenza”, San Giovanni Rotondo, Italy
| | - Luigi Amoruso
- Unit of Neurology, IRCCS “Casa Sollievo della Sofferenza”, San Giovanni Rotondo, Italy
| | - Michele Gravina
- Unit of Neuro-Rehabilitation, IRCCS “Casa Sollievo della Sofferenza”, San Giovanni Rotondo, Italy
| | - Filomena Di Rienzo
- Unit of Neuro-Rehabilitation, IRCCS “Casa Sollievo della Sofferenza”, San Giovanni Rotondo, Italy
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Wang Y, Huan X, Jiao K, Jiang Q, Goh LY, Shi J, Lv Z, Xi J, Song J, Yan C, Lin J, Zhu W, Zhu X, Zhou Z, Xia R, Luo S, Zhao C. Plasma exchange versus intravenous immunoglobulin in AChR subtype myasthenic crisis: A prospective cohort study. Clin Immunol 2022; 241:109058. [PMID: 35690385 DOI: 10.1016/j.clim.2022.109058] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Revised: 05/31/2022] [Accepted: 06/03/2022] [Indexed: 11/03/2022]
Abstract
Myasthenic crisis (MC) is a life-threatening state with respiratory failure in patients with myasthenia gravis (MG). The fast-acting immunomodulatory therapies for treating MC included plasma exchange (PE) and intravenous immunoglobulin (IVIG). However, the efficacy and the impact on antibody changes remained unknown. We prospectively followed 40 anti-acetylcholine receptors (AChR) antibody-positive MC patients who received either PE (n = 12) or IVIG (n = 28) at crisis. PE was associated with a reduced ICU stay length (p = 0.018) and an early response by the average changes in MGFA-QMG (p = 0.003), MMT (p = 0.020), and ADL (p = 0.011) at one-week off-ventilation. However, the clinical efficacy was equally comparable in both groups after 1 month. Post-treatment hemoglobin drop was significant in both groups, while IVIG was associated with a significant reduction in anti-AChR antibody titers (p < 0.001). This analysis provides real-world evidence in supporting the use of PE as a fast-acting therapy for shortening the ICU stay in AChR-associated MC.
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Affiliation(s)
- Yuan Wang
- Department of Blood Transfusion, Huashan Hospital Fudan University, Shanghai 200040, China
| | - Xiao Huan
- Huashan Rare disease centre, Department of Neurology, Huashan Hospital Fudan University, Shanghai 200040, China; National Center for Neurological Disorders, Shanghai 200040, China
| | - Kexin Jiao
- Huashan Rare disease centre, Department of Neurology, Huashan Hospital Fudan University, Shanghai 200040, China; National Center for Neurological Disorders, Shanghai 200040, China
| | - Qilong Jiang
- First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Li-Ying Goh
- Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Jianquan Shi
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Zhiguo Lv
- Changchun University of Chinese Medicine Department of Neurology, The Affiliated Hospital of Changchun University of Chinese Medicine, Changchun 130000, China
| | - Jianying Xi
- Huashan Rare disease centre, Department of Neurology, Huashan Hospital Fudan University, Shanghai 200040, China; National Center for Neurological Disorders, Shanghai 200040, China
| | - Jie Song
- Huashan Rare disease centre, Department of Neurology, Huashan Hospital Fudan University, Shanghai 200040, China; National Center for Neurological Disorders, Shanghai 200040, China
| | - Chong Yan
- Huashan Rare disease centre, Department of Neurology, Huashan Hospital Fudan University, Shanghai 200040, China; National Center for Neurological Disorders, Shanghai 200040, China
| | - Jie Lin
- Huashan Rare disease centre, Department of Neurology, Huashan Hospital Fudan University, Shanghai 200040, China; National Center for Neurological Disorders, Shanghai 200040, China
| | - Wenhua Zhu
- Huashan Rare disease centre, Department of Neurology, Huashan Hospital Fudan University, Shanghai 200040, China; National Center for Neurological Disorders, Shanghai 200040, China
| | - Xinfang Zhu
- Department of Blood Transfusion, Huashan Hospital Fudan University, Shanghai 200040, China
| | - Zhirui Zhou
- Radiation Oncology Center, Huashan Hospital, Fudan University, Shanghai, China
| | - Rong Xia
- Department of Blood Transfusion, Huashan Hospital Fudan University, Shanghai 200040, China.
| | - Sushan Luo
- Huashan Rare disease centre, Department of Neurology, Huashan Hospital Fudan University, Shanghai 200040, China; National Center for Neurological Disorders, Shanghai 200040, China.
| | - Chongbo Zhao
- Huashan Rare disease centre, Department of Neurology, Huashan Hospital Fudan University, Shanghai 200040, China; National Center for Neurological Disorders, Shanghai 200040, China.
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Erfani Z, Jelodari Mamaghani H, Rawling JA, Eajazi A, Deever D, Mirmoeeni S, Azari Jafari A, Seifi A. Pneumonia in Nervous System Injuries: An Analytic Review of Literature and Recommendations. Cureus 2022; 14:e25616. [PMID: 35784955 PMCID: PMC9249029 DOI: 10.7759/cureus.25616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/02/2022] [Indexed: 11/09/2022] Open
Abstract
Pneumonia is one of the most common complications in intensive care units and is the most common nosocomial infection in this setting. Patients with neurocritical conditions who are admitted to ICUs are no exception, and in fact, are more prone to infections such as pneumonia because of factors such as swallow dysfunction, need for mechanical ventilation, longer length of stay in hospitals, etc. Common central nervous system pathologies such as ischemic stroke, traumatic brain injury, subarachnoid hemorrhage, intracerebral hemorrhage, neuromuscular disorders, status epilepticus, and demyelinating diseases can cause long in-hospital admissions and increase the risk of pneumonia each with a mechanism of its own. Brain injury-induced immunosuppression syndrome is usually considered the common mechanism through which patients with critical central nervous system conditions become susceptible to different kinds of infection including pneumonia. Evaluating the patients and assessment of the risk factors can lead our attention toward better infection control in this population and therefore decrease the risk of infections in central nervous system injuries.
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Nelke C, Stascheit F, Eckert C, Pawlitzki M, Schroeter CB, Huntemann N, Mergenthaler P, Arat E, Öztürk M, Foell D, Schreiber S, Vielhaber S, Gassa A, Stetefeld H, Schroeter M, Berger B, Totzeck A, Hagenacker T, Meuth SG, Meisel A, Wiendl H, Ruck T. Independent risk factors for myasthenic crisis and disease exacerbation in a retrospective cohort of myasthenia gravis patients. J Neuroinflammation 2022; 19:89. [PMID: 35413850 PMCID: PMC9005160 DOI: 10.1186/s12974-022-02448-4] [Citation(s) in RCA: 33] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 03/29/2022] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Myasthenic crisis (MC) and disease exacerbation in myasthenia gravis (MG) are associated with significant lethality and continue to impose a high disease burden on affected patients. Therefore, we sought to determine potential predictors for MC and exacerbation as well as to identify factors affecting outcome. METHODS We examined a retrospective, observational cohort study of patients diagnosed with MG between 2000 and 2021 with a mean follow-up of 62.6 months after diagnosis from eight tertiary hospitals in Germany. A multivariate Cox regression model with follow-up duration as the time variable was used to determine independent risk factors for MC and disease exacerbation. RESULTS 815 patients diagnosed with MG according to national guidelines were included. Disease severity at diagnosis (quantitative MG score or Myasthenia Gravis Foundation of America class), the presence of thymoma and anti-muscle specific tyrosine kinase-antibodies were independent predictors of MC or disease exacerbation. Patients with minimal manifestation status 12 months after diagnosis had a lower risk of MC and disease exacerbation than those without. The timespan between diagnosis and the start of immunosuppressive therapy did not affect risk. Patients with a worse outcome of MC were older, had higher MGFA class before MC and at admission, and had lower vital capacity before and at admission. The number of comorbidities, requirement for intubation, prolonged mechanical ventilation, and MC triggered by infection were associated with worse outcome. No differences between outcomes were observed comparing treatments with IVIG (intravenous immunoglobulin) vs. plasma exchange vs. IVIG together with plasma exchange. CONCLUSIONS MC and disease exacerbations inflict a substantial burden of disease on MG patients. Disease severity at diagnosis and antibody status predicted the occurrence of MC and disease exacerbation. Intensified monitoring with emphasis on the prevention of infectious complications could be of value to prevent uncontrolled disease in MG patients.
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Affiliation(s)
- Christopher Nelke
- Department of Neurology, Medical Faculty, Heinrich Heine University Düsseldorf, Moorenstraße 5, 40225, Duesseldorf, Germany.,Department of Neurology with Institute of Translational Neurology, University and University Hospital Münster, Munster, Germany
| | - Frauke Stascheit
- Charité, Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Department of Neurology With Experimental Neurology, Humboldt-Universität zu Berlin, Berlin, Germany.,Charité, Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, NeuroCure Clinical Research Center, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Carmen Eckert
- Department of Neurology with Institute of Translational Neurology, University and University Hospital Münster, Munster, Germany
| | - Marc Pawlitzki
- Department of Neurology, Medical Faculty, Heinrich Heine University Düsseldorf, Moorenstraße 5, 40225, Duesseldorf, Germany.,Department of Child and Adolescent Psychiatry and Psychotherapy, University Hospital Münster, Munster, Germany
| | - Christina B Schroeter
- Department of Neurology, Medical Faculty, Heinrich Heine University Düsseldorf, Moorenstraße 5, 40225, Duesseldorf, Germany
| | - Niklas Huntemann
- Department of Neurology, Medical Faculty, Heinrich Heine University Düsseldorf, Moorenstraße 5, 40225, Duesseldorf, Germany
| | - Philipp Mergenthaler
- Charité, Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Department of Neurology With Experimental Neurology, Humboldt-Universität zu Berlin, Berlin, Germany.,Charité, Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, NeuroCure Clinical Research Center, Humboldt-Universität zu Berlin, Berlin, Germany.,Department of Neurology and Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Ercan Arat
- Department of Neurology, Medical Faculty, Heinrich Heine University Düsseldorf, Moorenstraße 5, 40225, Duesseldorf, Germany
| | - Menekse Öztürk
- Department of Neurology, Medical Faculty, Heinrich Heine University Düsseldorf, Moorenstraße 5, 40225, Duesseldorf, Germany
| | - Dirk Foell
- Department for Pediatric Rheumatology and Immunology, University of Münster, Munster, Germany
| | - Stefanie Schreiber
- Department of Neurology, University of Magdeburg, Magdeburg, Germany.,German Center for Neurodegenerative Diseases, Bonn, Germany.,Center for Behavioral Brain Sciences, Magdeburg, Germany
| | - Stefan Vielhaber
- Department of Neurology, University of Magdeburg, Magdeburg, Germany.,German Center for Neurodegenerative Diseases, Bonn, Germany.,Center for Behavioral Brain Sciences, Magdeburg, Germany
| | - Asmae Gassa
- Department of Cardiothoracic Surgery, University of Cologne and University Hospital Cologne, Cologne, Germany
| | - Henning Stetefeld
- Department of Neurology, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Michael Schroeter
- Department of Neurology, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Benjamin Berger
- Clinic of Neurology and Neurophysiology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Andreas Totzeck
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Tim Hagenacker
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Sven G Meuth
- Department of Neurology, Medical Faculty, Heinrich Heine University Düsseldorf, Moorenstraße 5, 40225, Duesseldorf, Germany
| | - Andreas Meisel
- Charité, Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Department of Neurology With Experimental Neurology, Humboldt-Universität zu Berlin, Berlin, Germany.,Charité, Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, NeuroCure Clinical Research Center, Humboldt-Universität zu Berlin, Berlin, Germany.,Charité, Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Center for Stroke Research Berlin, Humboldt-Universität zu Berlin, Berlin, Germany.,German Myasthenia Gravis Society, Berlin, Germany
| | - Heinz Wiendl
- Department of Neurology with Institute of Translational Neurology, University and University Hospital Münster, Munster, Germany
| | - Tobias Ruck
- Department of Neurology, Medical Faculty, Heinrich Heine University Düsseldorf, Moorenstraße 5, 40225, Duesseldorf, Germany. .,Department of Neurology with Institute of Translational Neurology, University and University Hospital Münster, Munster, Germany.
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Mergenthaler P, Stetefeld HR, Dohmen C, Kohler S, Schönenberger S, Bösel J, Gerner ST, Huttner HB, Schneider H, Reichmann H, Fuhrer H, Berger B, Zinke J, Alberty A, Kleiter I, Schneider-Gold C, Roth C, Dunkel J, Steinbrecher A, Thieme A, Lee DH, Linker RA, Angstwurm K, Meisel A, Neumann B. Seronegative myasthenic crisis: a multicenter analysis. J Neurol 2022; 269:3904-3911. [PMID: 35389099 PMCID: PMC8988104 DOI: 10.1007/s00415-022-11023-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 02/07/2022] [Accepted: 02/10/2022] [Indexed: 11/26/2022]
Abstract
Myasthenic crisis (MC) is a life-threatening condition for patients with myasthenia gravis (MG). Seronegative patients represent around 10–15% of MG, but data on outcome of seronegative MCs are lacking. We performed a subgroup analysis of patients who presented with MC with either acetylcholine-receptor-antibody-positive MG (AChR-MG) or seronegative MG between 2006 and 2015 in a retrospective German multicenter study. We identified 15 seronegative MG patients with 17 MCs and 142 AChR-MG with 159 MCs. Seronegative MCs were younger (54.3 ± 14.5 vs 66.5 ± 16.3 years; p = 0.0037), had a higher rate of thymus hyperplasia (29.4% vs 3.1%; p = 0.0009), and were more likely to be female (58.8% vs 37.7%; p = 0.12) compared to AChR-MCs. Time between diagnosis of MG and MC was significantly longer in seronegative patients (8.2 ± 7.6 vs 3.1 ± 4.4 years; p < 0.0001). We found no differences in duration of mechanical ventilation (16.2 ± 15.8 vs 16.5 ± 15.9 days; p = 0.94) and length of stay at intensive care unit (17.6 ± 15.2 vs 17.8 ± 15.4 days; p = 0.96), or in-hospital mortality (11.8% vs. 10.1%; p = 0.69). We conclude that MC in seronegative MG affects younger patients after a longer period of disease, but that crisis treatment efficacy and outcome do not differ compared to AChR-MCs.
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Affiliation(s)
- Philipp Mergenthaler
- Charité - Universitätsmedizin Berlin, Department of Neurology with Experimental Neurology, Neuroscience Clinical Research Center, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Center for Stroke Research Berlin, Berlin, Germany
- Berlin Institute of Health at Charité-Universitätsmedizin Berlin, BIH Academy, 10117 Berlin, Germany
| | - Henning R. Stetefeld
- Faculty of Medicine, Department of Neurology, University of Cologne, University Hospital Cologne, Cologne, Germany
| | - Christian Dohmen
- Faculty of Medicine, Department of Neurology, University of Cologne, University Hospital Cologne, Cologne, Germany
- Department of Neurology, LVR-Klinik Bonn, Bonn, Germany
| | - Siegfried Kohler
- Charité - Universitätsmedizin Berlin, Department of Neurology with Experimental Neurology, Neuroscience Clinical Research Center, Berlin, Germany
| | | | - Julian Bösel
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
- Department of Neurology, Klinikum Kassel, Kassel, Germany
| | - Stefan T. Gerner
- Department of Neurology, University Hospital Erlangen, Erlangen, Germany
- Department of Neurology, Universitätsklinikum Gießen Und Marburg, Giesen, Germany
| | - Hagen B. Huttner
- Department of Neurology, University Hospital Erlangen, Erlangen, Germany
- Department of Neurology, Universitätsklinikum Gießen Und Marburg, Giesen, Germany
| | - Hauke Schneider
- Department of Neurology, University Hospital, Technische Universität Dresden, Dresden, Germany
- Department of Neurology, University Hospital Augsburg, Augsburg, Germany
| | - Heinz Reichmann
- Department of Neurology, University Hospital, Technische Universität Dresden, Dresden, Germany
| | - Hannah Fuhrer
- Clinic of Neurology and Neurophysiology, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Benjamin Berger
- Clinic of Neurology and Neurophysiology, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Jan Zinke
- Hans Berger Department of Neurology, Jena University Hospital, Jena, Germany
| | - Anke Alberty
- Department of Neurology, Kliniken Maria Hilf GmbH Moenchengladbach, Mönchengladbach, Germany
| | - Ingo Kleiter
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany
- Marianne-Strauß-Klinik, Behandlungszentrum Kempfenhausen Für Multiple Sklerose Kranke gGmbH, Berg, Germany
| | | | - Christian Roth
- Department of Neurology, DRK-Kliniken Nordhessen, Kassel, Germany
- Department of Neurology, Philipps University of Marburg, Marburg, Germany
| | - Juliane Dunkel
- Department of Neurology, DRK-Kliniken Nordhessen, Kassel, Germany
| | | | - Andrea Thieme
- Department of Neurology, Helios Klinikum Erfurt, Erfurt, Germany
| | - De-Hyung Lee
- Department of Neurology, University of Regensburg, Bezirksklinikum, Regensburg, Germany
| | - Ralf A. Linker
- Department of Neurology, University of Regensburg, Bezirksklinikum, Regensburg, Germany
| | - Klemens Angstwurm
- Department of Neurology, University of Regensburg, Bezirksklinikum, Regensburg, Germany
| | - Andreas Meisel
- Charité - Universitätsmedizin Berlin, Department of Neurology with Experimental Neurology, Neuroscience Clinical Research Center, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Center for Stroke Research Berlin, Berlin, Germany
- Berlin Institute of Health at Charite-Universitatsmedizin Berlin, Berlin, Germany
| | - Bernhard Neumann
- Department of Neurology, University of Regensburg, Bezirksklinikum, Regensburg, Germany
- Present Address: Department of Neurology, Donau-Isar-Klinikum Deggendorf, Deggendorf, Germany
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Galassi G, Marchioni A. Acute neuromuscular syndromes with respiratory failure during COVID-19 pandemic: where we stand and challenges ahead. J Clin Neurosci 2022; 101:264-275. [PMID: 35660960 PMCID: PMC9050587 DOI: 10.1016/j.jocn.2022.03.048] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Revised: 03/15/2022] [Accepted: 03/29/2022] [Indexed: 12/15/2022]
Abstract
Coronavirus disease 2019 (COVID-19), a disease caused by the novel betacoronavirus SARS-COV-2, has become a global pandemic threat. SARS- COV-2 is structurally similar to SARS-COV, and both bind to the angiotensin-converting enzyme 2 (ACE2) receptor to enter human cells. While patients typically present with fever, shortness of breath, sore throat, and cough, in some cases neurologic manifestations occur due to both direct and indirect involvement of the nervous system. Case reports include anosmia, ageusia, central respiratory failure, stroke, acute necrotizing hemorrhagic encephalopathy, toxic-metabolic encephalopathy, headache, myalgia, myelitis, ataxia, and various neuropsychiatric manifestations. Some patients with COVID-19 may present with concurrent acute neuromuscular syndromes such as myasthenic crisis (MC), Guillain–Barré syndrome (GBS) and idiopathic inflammatory myopathies (IIM); these conditions coupled with respiratory failure could trigger a life-threatening condition. Here, we review the current state of knowledge on acute neuromuscular syndromes with respiratory failure related to COVID-19 infection in an attempt to clarify and to manage the muscle dysfunction overlapping SARS-COV-2 infection.
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45
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Galassi G, Marchioni A. Comment on case series of COVID-19 in patients with myasthenia gravis: a single institution experience by Županić et al. Acta Neurol Belg 2022; 122:559-560. [PMID: 34608594 PMCID: PMC8489789 DOI: 10.1007/s13760-021-01746-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Accepted: 07/02/2021] [Indexed: 11/25/2022]
Affiliation(s)
- Giuliana Galassi
- Department of Biomedical, Metabolic, and Neural Sciences, University Hospital, Via P Giardini, 1350, 41010, Modena, Italy.
| | - Alessandro Marchioni
- Respiratory Diseases Unit, University Hospital, Via P Giardini, 1350, 41010, Modena, Italy
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Iori E, Ariatti A, Mazzoli M, Bastia E, Gozzi M, Agnoletto V, Marchioni A, Galassi G. Cardiac disorders worsen the final outcome in myasthenic crisis undergoing non-invasive mechanical ventilation: a retrospective 20-year study from a single center. ACTA MYOLOGICA : MYOPATHIES AND CARDIOMYOPATHIES : OFFICIAL JOURNAL OF THE MEDITERRANEAN SOCIETY OF MYOLOGY 2022; 41:15-23. [PMID: 35465341 PMCID: PMC9004337 DOI: 10.36185/2532-1900-064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 03/07/2022] [Indexed: 01/24/2023]
Abstract
The study was performed to evaluate the impact of cardiological disorders on the outcome of myasthenic crisis (MC) requiring ventilation. The study includes 90 cases admitted to the Neurology Unit of Modena, Italy (January 2000 - September 2020). All patients were eligible for a non-invasive ventilation (NIV) trial. We analyzed the effect of cardiac comorbidities on the outcomes, which were the need of invasive ventilation, the risk tracheostomy for weaning failure and the duration of intensive care unit (ICU) stay Females were 58.9% and males 41.1%. Median age at diagnosis was 59 and at MC was 65. Patients were classified as early (EOMG) or late (LOMG), 34.4 and 65.6% respectively, according to age above or below 50; 85% of patients were anti- AChR antibody positive. Hypertension and cardiac diseases occurred at the diagnosis in 61 and 44.4%, respectively. Invasive mechanical ventilation (MV) was needed in 34% of cases. Nine subjects (10%) underwent tracheostomy because of weaning failure. Independent predictors of NIV failure were atrial fibrillation (AF), either parossistic or persistent (OR 3.05, p < 0.01), hypertensive cardiopathy (HHD) (OR 2.52, p < 0.01) and ischaemic heart disease (IHD) (OR 3.08, p < 0.01). Hypertension (HT) had no statistical effect on the outcomes. HHD was a predictor of weaning failure (OR 4.01, p = 0.017). Our study shows that HHD, AF and IHD increase the risk of NIV failure in MC receiving ventilation.
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Affiliation(s)
- Erika Iori
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena, Italy
| | - Alessandra Ariatti
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena, Italy
| | - Marco Mazzoli
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena, Italy
| | - Elisabetta Bastia
- Division of Cardiology, Baggiovara Hospital, Azienda Ospedaliera Universitaria, Modena, Italy
| | - Manuela Gozzi
- Radiology, Azienda Ospedaliera Universitaria, Modena, Italy
| | - Virginia Agnoletto
- Division of Cardiology, Baggiovara Hospital, Azienda Ospedaliera Universitaria, Modena, Italy
| | | | - Giuliana Galassi
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena, Italy,Correspondence Giuliana Galassi Department of Biomedical, Metabolic and Neural Sciences, University of Modena, via P. Giardini 454, 41124 Modena, Italy. Tel: + 39 059 3497325801. Fax. + 39 059 367961. E-mail:
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Comment on “Non-invasive mechanical ventilation in Myasthenic crisis outside Intensive Care Unit setting: a safe step?” by Di Costanzo et al. Neuromuscul Disord 2022; 32:540-541. [PMID: 35501274 PMCID: PMC9054570 DOI: 10.1016/j.nmd.2022.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 03/03/2022] [Accepted: 03/08/2022] [Indexed: 11/22/2022]
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Soares Ferreira Júnior A, Boyle SH, Kuchibhatla M, Onwuemene OA. Central venous catheters are associated with thrombosis among adult inpatients undergoing therapeutic plasma exchange. J Clin Apher 2022; 37:340-347. [PMID: 35191546 DOI: 10.1002/jca.21975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 02/07/2022] [Accepted: 02/08/2022] [Indexed: 11/12/2022]
Abstract
BACKGROUND For inpatients undergoing therapeutic plasma exchange (TPE) in the United States, the primary mode of venous access is the central venous catheter (CVC). To evaluate the impact of CVC on thrombosis outcomes of patients undergoing TPE, we analyzed the National Inpatient Sample (NIS) database. STUDY DESIGN AND METHODS In a cross-sectional analysis of the NIS, we identified hospital discharges of adult patients treated with TPE. Cases were classified into two groups based on CVC status. The primary outcome was thrombosis. Secondary outcomes were major bleeding, packed red blood cell (PRBC) transfusion, in-hospital mortality, hospital length of stay (LOS), and charges. RESULTS Among 9863 TPE-treated discharges, CVC was used in 5988 (60%). These numbers correspond to weighted national estimates of 49 315 and 29 940, respectively. There was a positive and significant association between CVC and thrombosis (OR = 1.23, 95% 1.04-1.46, P = 0.0174), PRBC transfusion (OR = 1.15, 95% 1.03-1.29, P = 0.0121), in-hospital mortality (OR = 1.36, 95% 1.10-1.68, P = 0.0043), hospital LOS (15.63 vs 12.45 days, P < 0.0001) and hospital charges ($166 387 vs. $132 655, P < 0.0001). CONCLUSION In hospitalized patients undergoing TPE, CVC use is associated with increased rates of thrombosis. Future studies are needed to investigate strategies to decrease CVC use and/or prevent CVC-associated complications in TPE-treated inpatients.
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Affiliation(s)
| | - Stephen H Boyle
- Duke University School of Medicine, Durham, North Carolina, USA.,Durham Veterans Administration Medical Center, Durham, North Carolina, USA
| | - Maragatha Kuchibhatla
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Oluwatoyosi A Onwuemene
- Division of Hematology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
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Lin J, Xiang Q, Liu X, Li J. Risk Factors and Prognosis in Patients With Anti-N-Methyl-D-Aspartate Receptor Encephalitis Requiring Prolonged Mechanical Ventilation. Front Neurol 2022; 13:814673. [PMID: 35222249 PMCID: PMC8863869 DOI: 10.3389/fneur.2022.814673] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Accepted: 01/11/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundMechanical ventilation (MV) is commonly used in anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis patients with serious conditions. However, little is known about the potential risk factors and long-term outcomes of anti-NMDAR encephalitis requiring MV, especially prolonged MV.MethodsThe data collected prospectively from 305 patients with anti-NMDAR encephalitis were retrospectively reviewed. The functional outcome was assessed using a modified Rankin scale (mRS) every 3 months.ResultsWe identified 62 (20.3%) patients who required MV. The most common reasons for MV were decreased consciousness and/or status epilepticus (SE). Among 60 patients analyzed, 27 patients required prolonged MV (>15 days). Prolonged MV primarily was based on the younger age, coma, tumor, and severe pneumonia. During the follow-up (median: 28 months, range: 3–87 months), 77% of patients required MV that exhibited a good outcome. In univariate analysis, prolonged MV, higher levels of C-reactive protein (CRP), and neutrophil-to-lymphocyte ratio (NLR) were found to be associated with poor neurological outcome at 6 months. Although the prolonged MV group exhibited a longer time to achieve a good outcome as compared to the short MV group (median duration 6 months vs. 3 months, p = 0.004), no significant difference was observed between the two groups about long-term outcomes.ConclusionIt is important to recognize that most anti-NMDAR encephalitis patients who required MV will achieve a favorable long-term outcomes, despite the longer duration of MV. Our results may help clinicians in the ventilator management of severe anti-NMDAR encephalitis patients.
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Affiliation(s)
- Jingfang Lin
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Qu Xiang
- West China Biomedical Big Data Center, West China Hospital, Chengdu, China
| | - Xu Liu
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Jinmei Li
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
- *Correspondence: Jinmei Li
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Lotan I, Hellmann MA, Friedman Y, Stiebel-Kalish H, SteinerMD I, Wilf-Yarkoni A. Early Safety and Tolerability Profile of the BNT162b2 COVID-19 Vaccine in Myasthenia Gravis. Neuromuscul Disord 2022; 32:230-235. [PMID: 35227552 PMCID: PMC8817458 DOI: 10.1016/j.nmd.2022.01.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 01/25/2022] [Accepted: 01/27/2022] [Indexed: 12/13/2022]
Abstract
Although the COVID-19 vaccines are currently recommended for people with myasthenia gravis (MG), there is no data regarding the safety of the vaccines in this population. In order to investigate the real-life safety data of the BNT162b2 COVID-19 vaccine in people with MG, an anonymous survey was distributed to 142 MG patients. Fifty-six MG patients completed the questionnaire. The median age was 53 years (range 23–83 years); 35 (62.5%) were males, and 25 (44.6%) had associated comorbidities. Thirty-seven participants (66.1%) were treated with immunotherapies. Fifty-five participants (98.2% of the responders) received the BNT162b2 COVID-19 vaccine. Of these, 32 (58.2%) were < 55 years old, and 23 (41.8%) were > 55 years old. Adverse events were more common in patients younger than 55 years old (46.9% Vs. 17.4%; p = 0.0428). Eight participants (14.5%) reported worsening neurological symptoms following the vaccination. Three of those who reported worsening of neurological symptoms (37.5%) required additional treatment. Most events occurred within the first few days after vaccination and resolved within a few weeks. This survey indicates an overall favorable safety and tolerability profile of the BNT162b2 vaccine in people with MG. Additional prospective, large-scale studies are warranted to confirm these findings.
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